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 C

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. Clients undergoing stem cell transplants are immunocompromised due to chemotherapy and conditioning regimens. To reduce the risk of infection, all equipment that comes into contact with the client, such as blood pressure cuffs, should be dedicated to that room only. This prevents cross-contamination from other patients.
D. Negative pressure rooms are for protecting others from airborne infections (e.g., TB). Stem cell transplant clients require positive pressure rooms to protect them from pathogens in the environment.

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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. A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min B. A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky. C. An unconscious adult client who has a large head wound with gray matter exposed; absent respirations D. An unconscious 6-month-old infant with no respirations, no visible injuries

Correct Answer is A

Explanation

A. In mass casualty triage, priority is given to clients who are salvageable with immediate intervention. This client is conscious (airway is intact) but has respiratory distress (RR > 30/min), suggesting potential inhalation injury or early shock. Prompt treatment can be life-saving.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C.Unconscious adult with large head wound and exposed gray matter, absent respirationsis unsalvageable; in triage terms, this client would be black tag (expectant). Immediate care will not change survival.

D.Unconscious 6-month-old infant with no respirations, no visible injuriesis also considered unsalvageable without immediate resuscitation; triage prioritizes those with highest likelihood of survival.

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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

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