A nurse is planning care for a client who is to undergo a stem cell transplant.
Which of the following actions should the nurse plan to take?
Provide the client with 1,000 mL of water to drink every 12 hr.
Keep blood pressure equipment in the client's room.
Place the client in a negative airflow room.
Monitor the client's vital signs once every 8 hr.
The Correct Answer is B
Choice A rationale
Providing 1,000 mL of water every 12 hours is not directly related to preventing infection or other complications post-transplant.
Choice B rationale
Keeping blood pressure equipment in the client's room helps prevent cross-contamination and infection by not sharing equipment with other clients.
Choice C rationale
A negative airflow room is used for clients with airborne infections, not for those undergoing a stem cell transplant.
Choice D rationale
Monitoring vital signs every 8 hours is insufficient; more frequent monitoring is needed post-transplant to detect complications early.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Dark stools are not a common side effect of chemotherapy; this symptom typically indicates gastrointestinal bleeding or iron supplements.
Choice B rationale
Flossing 4 times daily can cause gum irritation and bleeding, increasing the risk of infection in immunocompromised clients.
Choice C rationale
Administering an antiemetic before chemotherapy helps to prevent nausea and vomiting, improving the client's comfort and compliance with treatment.
Choice D rationale
Swishing with commercial mouthwash can irritate the mucous membranes; instead, using a gentle saline rinse is recommended.
Correct Answer is C
Explanation
Choice A rationale
Systemic lupus erythematosus (SLE) does not originate in the peripheral vascular system. This system involves the blood vessels outside of the heart and brain, and while SLE can affect these vessels, it is not the primary origin of the disease.
Choice B rationale
SLE does not originate in muscle tissue. Muscle involvement in SLE typically results from inflammation caused by the autoimmune response, but muscle tissue is not the source of the disease.
Choice C rationale
Connective tissue is where SLE originates. SLE is an autoimmune disease that primarily targets connective tissue, causing inflammation and damage to various organs and systems throughout the body.
Choice D rationale
The lymphatic system is not the origin of SLE. While the immune system plays a key role in SLE, the disease itself originates in the connective tissue, not the lymphatic system.
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