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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Avoiding crowds is to prevent the client from getting infections due to immunosuppression, not to prevent spreading infection to others, thus an incorrect rationale.
Choice B rationale:
Running a toothbrush through a dishwasher may seem hygienic but is generally unnecessary. More effective measures are needed to ensure oral hygiene without excessive sterilization.
Choice C rationale
Antiemetics are typically taken prior to or at the first sign of nausea during chemotherapy, not after the infusion is complete, so this statement is incorrect regarding the timing of antiemetic use.
Choice D rationale
Calling the doctor for unusual menstrual bleeding is crucial as it can indicate thrombocytopenia, a potential side effect of chemotherapy, reflecting the client's correct understanding.
Correct Answer is C
Explanation
Choice A rationale
Restricting activities that could result in bleeding is important for patients with thrombocytopenia, which is different from neutropenia; neutropenic precautions focus on infection prevention.
Choice B rationale
Restricting all visitors might be overly restrictive; instead, visitors should be screened for infections, and hand hygiene should be emphasized to prevent infection transmission.
Choice C rationale
Fresh flowers and potted plants can harbor bacteria and fungi that pose an infection risk to immunocompromised clients, such as those with neutropenia, making this restriction important.
Choice D rationale
Restricting oral fluid intake to between meals only is not necessary for managing neutropenia; maintaining good hydration is important, and there are no specific fluid timing restrictions.
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