A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?

Monitor the client's vital signs once every 8 hr.

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.

Answer and Explanation

The Correct Answer is D

A. Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Keeping blood pressure equipment in the client's room is necessary but does not directly address infection control, which is critical in stem cell transplant recipients.
D. Placing the client in a negative airflow room is crucial to reduce the risk of infections, which are a major concern in immunocompromised clients undergoing stem cell transplantation.

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Correct Answer is C

Explanation

A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.

A. Remove both of the elastic bandages from the leg B. Obtain a prescription for pain medication. C. Discharge the client. D. Obtain a prescription for the appropriate anti-venom.

Correct Answer is D

Explanation

A. Removing the elastic bandages could lead to rapid systemic absorption of venom, increasing the severity of envenomation.
B. Pain management is important but secondary to administering anti-venom in cases of snakebite.
C. Discharging the client without proper evaluation and treatment for potential envenomation could lead to serious complications.
D. Administering the appropriate anti-venom is critical to neutralize venom effects and prevent worsening of symptoms.

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A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Correct Answer is C

Explanation

A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?