The patient is admitted for chemotherapy, but the nurse notices laboratory values indicating that the patient is immunosuppressed. The nurse should

tell staff that hand washing is not recommended when working with this patient.

avoid the use of antimicrobial soaps when bathing and providing perinea care.

start as many intravenous lines as possible to provide potential antibiotics.

place the patient in a single room with a HEPA filtration system,

Answer and Explanation

The Correct Answer is D

Rationale:
A. This is incorrect because hand hygiene is the most critical intervention to prevent infection in immunosuppressed patients. Staff should strictly wash hands before and after all patient contact. Omitting hand washing would increase the risk of life-threatening infections.

B. This is incorrect because antimicrobial soaps are safe and often recommended for bathing immunosuppressed patients to reduce the risk of infection. Avoiding them could increase susceptibility to pathogens.

C. This is incorrect because placing multiple intravenous lines unnecessarily increases the risk of infection and does not prevent immunosuppression-related complications. IV lines should only be used as clinically indicated.

D. This is correct because placing the patient in a single room with HEPA filtration helps reduce exposure to airborne pathogens, which is essential for severely immunocompromised patients, such as those undergoing chemotherapy. Additional precautions include limiting visitors, using protective equipment, and maintaining strict aseptic technique during procedures.

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Correct Answer is C

Explanation

Rationale:
A. This is incorrect because although airway support may eventually be needed, the priority problem suggested by absent breath sounds on one side with hypotension and hypoxia is a tension pneumothorax, which must be treated immediately. Intubation alone does not relieve trapped air and can actually worsen the condition.

B. This is incorrect because a chest x-ray should not delay emergency treatment. In a suspected tension pneumothorax, the diagnosis is clinical, and immediate intervention is required to prevent cardiovascular collapse.

C. This is correct because absent breath sounds on one side, falling oxygen saturation, and hypotension after chest trauma are classic signs of a tension pneumothorax. Emergency treatment is needle thoracostomy to rapidly relieve pressure, followed by chest tube insertion to allow continuous lung re-expansion and prevent recurrence.

D. This is incorrect because while hypotension may be present, it is due to impaired venous return from increased intrathoracic pressure, not fluid loss. Administering fluids does not correct the underlying cause and should not delay definitive treatment.

A. It is caused by dilation of the biliary system. B. It decreases the patient's metabolism. C. it increases pancreatic secretions D. it is caused by decreased distention of the pancreatic capsule.

Correct Answer is C

Explanation

Rationale:
A. It is caused by dilation of the biliary system is incorrect because, although gallstones and biliary obstruction can trigger acute pancreatitis, this option explains a possible cause of pancreatitis rather than why pain control is a nursing priority. It does not address the physiologic consequences of uncontrolled pain.

B. It decreases the patient’s metabolism is incorrect because pain typically increases metabolic demand and stress hormone release rather than decreasing metabolism. Uncontrolled pain leads to increased oxygen consumption and energy expenditure.

C. It increases pancreatic secretions is correct because pain and stress stimulate the sympathetic nervous system, which can increase pancreatic enzyme secretion. Increased enzyme release worsens pancreatic inflammation and autodigestion. Effective pain control helps reduce pancreatic stimulation, limits further tissue damage, and promotes healing.

D. It is caused by decreased distention of the pancreatic capsule is incorrect because pain in acute pancreatitis is associated with inflammation, edema, and increased distention of the pancreatic capsule, not decreased distention.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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