A nurse is reinforcing discharge teaching with the guardian of a client who is neutropenic. Which of the following instructions should the nurse include?
"You can take your child to stores on weekends."
"You should inspect your child's mouth weekly for ulcers."
"You should notify your provider if your child has a fever."
"You can give your child fresh fruit for snacks."
The Correct Answer is C
A nurse reinforcing discharge teaching with the guardian of a client who is neutropenic should include the instruction to notify the provider if the child has a fever. A fever can be a sign of infection, which can be serious in a client who is neutropenic.
The other options are not correct.
A client who is neutropenic should avoid crowded places such as stores to reduce their risk of infection. The guardian should inspect the child's mouth daily, not weekly, for ulcers. A client who is neutropenic should avoid fresh fruits as they may carry bacteria that can cause infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Weigh the client each morning after voiding
Rationale:
A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.
B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.
C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.
D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.
Correct Answer is D
Explanation
The nurse should recommend that the client who has diminished breath sounds and paradoxical chest movement receive care first. This client is likely experiencing a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.
Option a is incorrect because a client who has a head injury and whose pupils are fixed and dilated may have experienced brain death and may not be able to be resuscitated.
Option b is incorrect because a dislocated shoulder, while painful, is not immediately life-threatening. Option c is incorrect because a scalp laceration with intermittent bleeding can be managed with pressure and is not immediately life-threatening.
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