The nurse caring for a client with acute leukemia who is immunosuppressed is diligent about protecting the patient from infection. When visitors come in, in addition to having them put on neutropenic isolation, the registered nurse prohibits them from bringing a:

New pajama.

Well-done meat.

Beautiful potted plant.

A new iPad from the online store

Answer and Explanation

The Correct Answer is C

A. New pajamas are generally not a risk for infection and do not pose a significant threat to an immunosuppressed patient.
B. Well-done meat is safe for consumption and does not pose an infection risk in this context.
C. A potted plant can harbor soil-borne bacteria and fungi, posing a risk of infection to immunosuppressed patients and should be avoided.
D. A new iPad from the online store is unlikely to introduce infection and does not pose a significant risk.

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Correct Answer is C

Explanation

A. While assessing perianal skin integrity is important for managing ulcerative colitis, it is not the immediate priority. Addressing electrolyte imbalances is crucial for stabilizing the client's condition first.

B. Emotional concerns are important but are secondary to addressing immediate physical health needs, such as electrolyte imbalances, which can be life-threatening if not managed promptly.

C. Reviewing electrolyte values is critical in an acute exacerbation of ulcerative colitis because diarrhea and fluid loss can lead to significant electrolyte imbalances, which need to be corrected to prevent complications.

D. Obtaining a dietary history is relevant for overall management but is not the immediate priority. Addressing electrolyte imbalances and hydration status is more urgent in acute exacerbations.

A. Place the client on his left side in Trendelenburg position. B. Replace the infusion system. C. Remove the catheter. D. Prepare for chest tube insertion. E. Prepare for chest tube insertion.

Correct Answer is A

Explanation

A. Placing the client on their left side in Trendelenburg position (head down, feet up) helps trap any air in the right atrium and prevents it from entering the pulmonary circulation, reducing the risk of an air embolism affecting the lungs.

B. Replacing the infusion system does not address the immediate need to manage an air embolism. The primary intervention is positioning and monitoring.

C. Removing the catheter is not the initial priority. The focus should be on managing the air embolism and ensuring the client is in the correct position.

D. Preparing for chest tube insertion is not appropriate unless there is evidence of a pneumothorax or hemothorax. The immediate concern is managing the air embolism.

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The nurse caring for a client with acute leukemia who is immunosuppressed is diligent about protecting the patient from infection. When visitors come in, in addition to having them put on neutropenic isolation, the registered nurse prohibits them from bringing a:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

Correct Answer is A

Explanation

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