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. This client has respiratory distress but is conscious and stable, requiring urgent but not immediate attention compared to other critical conditions.
B. This client has a dislocated shoulder, which is painful and needs attention but is not life-threatening compared to other conditions.
C. This client is unconscious with a sucking chest wound and high respiratory rate, indicating severe respiratory compromise and needing immediate intervention to prevent further deterioration.
D. This client is also unconscious with no respirations despite attempted airway management, indicating a need for immediate resuscitative efforts, potentially including CPR.

A. The patient develops atrial fibrillation. B. The core temperature is 94° F (34.4" C). C. The BP decreases to 86/42 mm Hg. D. The patient begins to shiver

Correct Answer is B

Explanation

A. Developing atrial fibrillation can be a complication of hypothermia, but rewarming is still necessary to address the underlying condition.
B. Active rewarming should be discontinued if the patient's core temperature reaches 94°F (34.4°C), as further active rewarming could lead to complications. It's important to transition to passive rewarming methods to allow the patient's temperature to normalize gradually.
C. A decrease in blood pressure may indicate hypovolemia or shock but does not necessarily require discontinuation of rewarming.
D. Shivering is a normal response during rewarming and does not indicate a need to discontinue rewarming efforts unless other complications arise.

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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

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

Correct Answer is C

Explanation

Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?

Correct Answer is B

Explanation

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