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. Correct. The nurse should avoid including raw fruits in the client's diet because they can harbor bacteria and fungi that can cause infection in a client who has neutropenia, which is a low white blood cell count.
B. Incorrect. The nurse should limit visits from anyone who is sick or has been exposed to an infection, but there is no need to restrict visits from young children specifically, as long as they are healthy and follow proper hand hygiene.
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.
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Related Questions
Correct Answer is B
Explanation
A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain.
D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.
Correct Answer is A
Explanation
Correct answer: A. Have the child take a tub bath each morning
A. Have the child take a tub bath each morning: Warm tub baths are recommended for children with juvenile idiopathic arthritis (JIA) as they help to relieve joint stiffness and pain, especially in the morning. The warm water can soothe the joints, making movement easier and reducing discomfort throughout the day.
B. Apply splints to the child's extremities during the day: While splints may be used in JIA, they are typically applied during the night (resting splints) to maintain joint position and prevent contractures. Daytime use of splints (working splints) may be considered in certain situations, but generally, children are encouraged to be as active as possible during the day to maintain joint mobility.
C. Encourage the child to take naps during the day: While rest is important, encouraging too much rest during the day may contribute to joint stiffness. Regular activity helps maintain joint function and mobility, which is essential in managing JIA.
D. Keep the child on bedrest as long as pain persists: Prolonged bedrest is not recommended for children with JIA. It can lead to muscle atrophy, increased stiffness, and reduced joint mobility. Instead, the focus should be on maintaining activity within the child's pain tolerance and using pain management strategies.
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