A nurse is planning care for a client who is receiving chemotherapy and has neutropenia.
Which of the following interventions should the nurse include in the plan?
Avoid including raw fruits in the client's diet.
Restrict visits from young children to 2 hr per day.
Measure the client's temperature once per shift.
Use disposable gloves from a box outside the client's room.
The Correct Answer is A
- A. The nurse should discourage raw fruits due to risk of infection.
- B. There is no standard recommendation against exposure to young children.
- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A. Pink, frothy sputum is a characteristic finding of pulmonary edema, which is caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This impairs gas exchange and leads to hypoxia and respiratory distress.
- B. Bradycardia is not expected in pulmonary edema. The client is more likely to have tachycardia due to increased sympathetic stimulation and decreased cardiac output.
- C. Flushed, dry skin is not expected in pulmonary edema. The client is more likely to have pale, cool, and clammy skin due to peripheral vasoconstriction and decreased perfusion.
- D. Wheezing is not a specific finding of pulmonary edema. It may indicate bronchospasm or asthma, which are different conditions that affect the airways rather than the alveoli.
Correct Answer is D
Explanation
Ask the partner to list specific concerns.
- A. Evaluate the changes the partner requests: This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
- B. Review the client's plan of care: This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
- C. Analyze other reports of poor care to look for trends: This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
- D. Ask the partner to list specific concerns: This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.
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