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 C

Explanation

C. Paresthesia, or abnormal sensations like tingling, numbness, or burning, is a common neurological manifestation of pernicious anemia due to damage to the peripheral nerves caused by vitamin B12 deficiency. Paresthesia can affect balance and coordination, increasing the risk of falls and injuries, and thus posing a risk to the client's safety.
A. Loss of hearing is not typically associated with pernicious anemia.
B. Muscle wasting is not a typical manifestation of pernicious anemia. However, weakness and fatigue are common symptoms due to anemia resulting from decreased oxygen-carrying capacity of the blood.

D. While changes in vision can impact the client's safety, they are not as directly associated with pernicious anemia as paresthesia, which affects mobility and balance.

A. The client has 100 mL blood in the closed-suction drain. B. The client has an oral temperature of 38.3° C (100.9° F). C. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site. D. The client's capillary refill in the left toe is 6 seconds.

Correct Answer is D

Explanation

D. Capillary refill time greater than 2 seconds suggests impaired peripheral circulation, which could indicate vascular compromise or inadequate perfusion to the extremity. In a client with an external fixator, compromised circulation could lead to serious complications such as compartment syndrome or tissue necrosis.
A. This finding may be within the expected range for drainage following surgery, particularly if the client has undergone orthopedic surgery involving the placement of an external fixator. However, the nurse should continue to monitor the drainage and assess for any signs of increased bleeding or hematoma formation.
B. While a low-grade fever alone may not require immediate intervention, the nurse should assess the client further for other signs and symptoms of infection, such as increased pain, redness, warmth, or drainage at the surgical site.
C. While the client's pain level of 7 may require intervention to manage discomfort, it does not necessarily indicate an immediate threat to the client's safety or well-being.

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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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