A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take?

Monitor vital signs at least every 4 hr.

Insert an indwelling urinary catheter.

Change the client's linens three times a day.

Place the client in a room with negative airflow.

Answer and Explanation

The Correct Answer is A

A.   Frequent vitals monitoring to allow for early detection of infection. Clients with neutropenia are at increased risk of infections.
B.   Indwelling catheter and other devices should be avoided in individuals with neutropenia die to risk of sepsis.
C.   Changing the client’s linen is important. However, doing it 3 times a day is not necessary.
D.   Clients should be placed in a positive airflow room to prevent contracting infections from infected persons

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Correct Answer is D

Explanation

A. Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.

C.While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.

A. Emesis of 250 mL B. Increased respiratory rate to 26/min C. Decreased anxiety D. Decreased urinary output

Correct Answer is C

Explanation

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

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A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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