The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.

Encourage the client to cough and deep breathe.

Turn client every 2 hours.

Keep skin clean and dry.

Apply lotion to clean skin.

Help the client void.

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   Encouraging the client to cough and deep breathe helps to maintain clear airways and prevent respiratory infections.
B.   Turning the client every 2 hours is important for preventing pressure ulcers and maintaining skin integrity.
C.   Keeping the skin clean and dry helps to prevent skin breakdown and infections, serving as a barrier against pathogens.
D.   Applying lotion to clean skin may keep the skin moisturized hence preventing skin breakdown.

E.   Urinary incontinence is associated with skin breakdown hence the development of bedsores. Therefore, assisting the client with voiding is important for maintaining urinary function and skin integrity.

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Correct Answer is B

Explanation

A. Mild exercise like gardening may be suitable for some clients with leukopenia, but it is not a specific precaution related to their immune status.

B. Clients with leukopenia have reduced white blood cell counts, making them more susceptible to infections. Avoiding crowds helps reduce the risk of exposure to infectious agents.
C. Monitoring oral temperature weekly is important for early detection of infection.

However, it should be done more frequently, daily and not weekly.

D. While eating plenty of fresh fruits and vegetables is generally beneficial for overall health, a patient with leukopenia is encouraged to eat cooked foods due to their low immunity.

A. White blood cell count of 1,500 mm3 B. Hematocrit level at 35% C. Hemoglobin of 16 g/dL D. Platelet count of 150,000 per microliter

Correct Answer is A

Explanation

A. Neutropenic precautions are implemented when the white blood cell count is significantly decreased, typically below 1,000/mm3, to protect the client from potential infections due to compromised immunity.
B. Hematocrit level and hemoglobin levels are indicators of red blood cell function and oxygen-carrying capacity and are not directly related to neutropenia.

C. Hemoglobin levels are an indicator of oxygen-carrying capacity and are not directly related to neutropenia.
D. Platelet count is related to clotting function and is not directly related to neutropenia.

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The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with leukopenia is being discharged home. Which of the following should the nurse include in the teaching plan for this client?

Correct Answer is B

Explanation

The client is being admitted to the oncology unit and is being placed on neutropenic precautions. Which lab value would indicate the need for this type of precaution?

Correct Answer is A

Explanation

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