A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

"I will take my temperature daily."

"I will wash my toothbrush weekly."

"I will eat plenty of fresh fruits and vegetables."

"I will change my cat's litter box twice weekly."

"I will avoid crowds."

Answer and Explanation

Correct Answer : A,E

Rationale:

A. "I will take my temperature daily.": Daily temperature monitoring is essential for clients with neutropenia, as even a low-grade fever may be the only early sign of infection due to suppressed immune response. Prompt detection allows for early intervention and treatment.

B. "I will wash my toothbrush weekly.": A neutropenic client should wash or replace their toothbrush more frequently—ideally daily or after each use—to reduce the risk of bacterial growth and oral infections, which they are more vulnerable to.

C. "I will eat plenty of fresh fruits and vegetables.": Fresh, uncooked fruits and vegetables may carry harmful bacteria or fungi and should be avoided unless thoroughly washed or cooked. A neutropenic diet typically excludes raw produce to minimize infection risk.

D. "I will change my cat's litter box twice weekly.": Clients with neutropenia should avoid handling cat litter altogether, as it can harbor Toxoplasma gondii and other pathogens that pose a serious infection risk due to their weakened immune system.

E. "I will avoid crowds.": Avoiding crowds is critical for clients with neutropenia to reduce exposure to airborne and contact-transmissible pathogens, as even minor infections can become life-threatening in immunocompromised individuals.

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Correct Answer is A

Explanation

Rationale:
A. A pearly, waxy nodule: This is the classic presentation of basal cell carcinoma. These lesions often appear as small, shiny, flesh-colored or pink nodules with a translucent or pearly surface and may have visible blood vessels. They are slow-growing and rarely metastasize.

B. An irregular border on a variegated-colored lesion: This description is more indicative of malignant melanoma, which often appears as an asymmetric lesion with uneven borders and multiple colors, including black, brown, red, or white.

C. A firm, nodular, crusty, or ulcerated lesion: These characteristics are more commonly associated with squamous cell carcinoma, which tends to be more aggressive and can metastasize if untreated.

D. A weeping vesicle: This finding is consistent with inflammatory skin conditions such as contact dermatitis or eczema, not basal cell carcinoma. These vesicles are usually associated with allergic or irritant reactions.

A. Close the pinch clamp on the CVC. B. Obtain a prescription for stat ABGs. C. Place the client in left Trendelenburg position. D. Check the tubing for placement of a locking adaptor.

Correct Answer is C

Explanation

Rationale:
A. Close the pinch clamp on the CVC: Clamping the catheter is important to stop further air entry, but placing the client in the proper position takes priority to trap the air and prevent it from reaching the pulmonary circulation.

B. Obtain a prescription for stat ABGs: ABGs may help assess respiratory compromise, but they are not the immediate action. This diagnostic step should follow emergency interventions that prevent further complications from an air embolism.

C. Place the client in left Trendelenburg position: This is the priority action because it helps trap any air in the right atrium and prevents it from entering the pulmonary arteries, reducing the risk of a fatal air embolism. Positioning the client correctly is a critical first step in managing suspected air embolism.

D. Check the tubing for placement of a locking adaptor: Verifying equipment setup is important for preventing future incidents, but it does not address the client’s current critical condition. Immediate positioning takes precedence.

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A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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