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 B

Explanation

B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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