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 D

Explanation

A. Administering an expectorant is not primarily aimed at preventing pulmonary complications but rather at helping to clear mucus. While this can be part of respiratory care, it does not address the prevention of complications like atelectasis or pneumonia.

B. Performing range-of-motion exercises is important for overall mobility and prevention of deep vein thrombosis but does not specifically address the prevention of pulmonary complications.

C. Placing suction equipment at the bedside is useful for managing secretions but does not directly prevent pulmonary complications. It is a reactive measure rather than preventive.

D. Encouraging the use of an incentive spirometer is an effective method to prevent pulmonary complications such as atelectasis and pneumonia. It helps improve lung function by promoting deep breathing and expanding the alveoli.

A. Eyelets are not visible B. Crepitus in the area above and surrounding the insertion site C. Bubbling of the water in the water seal chamber with exhalation D. Movement of the trachea toward the unaffected side

Correct Answer is D

Explanation

A. Eyelets not being visible may be a normal finding, as they can be covered by the dressing. This is not necessarily indicative of a problem with the chest tube.

B. Crepitus, or subcutaneous emphysema, is concerning and should be monitored but is not immediately life-threatening compared to other signs of complications.

C. Bubbling in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning correctly. Continuous bubbling, however, may suggest an air leak.

D. Movement of the trachea toward the unaffected side is indicative of a mediastinal shift, which can occur due to tension pneumothorax or other significant complications. This is an urgent condition that requires immediate provider notification and intervention.

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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 developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Correct Answer is D

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is D

Explanation

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