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

D. Hot flashes are a common symptom following a bilateral orchiectomy due to the sudden decrease in testosterone levels. Hot flashes are characterized by sudden feelings of warmth, flushing, and sweating, often accompanied by a rapid heartbeat. These symptoms can be bothersome but are typically temporary and can be managed with lifestyle modifications and medications if necessary.
A. Hypoglycemia is not typically associated with a bilateral orchiectomy.
B. Testosterone, primarily produced by the testicles, plays a significant role in promoting muscle mass and strength. Removal of the testicles results in a significant decrease in testosterone production, which may lead to a gradual decline in muscle mass and strength over time.
C. Testosterone is a key hormone involved in regulating libido in both men and women. Removal of the testicles leads to a significant decrease in testosterone levels, which may result in a decrease in libido rather than an increase.

A. Increase the rate of infusion if administration is delayed. B. Monitor serum blood glucose during infusion. C. Verify the solution with another RN prior to infusion. D. Infuse 0.9% sodium chloride if the solution is not available. E. Obtain the client's weight daily.

Correct Answer is ["B","C","E"]

Explanation

B. Monitoring serum blood glucose during infusion is important because TPN can contain glucose, which may affect the client's blood glucose levels. Regular monitoring helps ensure glycemic control and prevents complications such as hyperglycemia.
C. Double-checking the TPN solution with another RN is a crucial safety measure to prevent medication errors and ensure that the correct solution is administered to the client.
E. Monitoring the client's weight daily is important for assessing fluid balance and adjusting the TPN infusion rate accordingly. Changes in weight can indicate fluid retention or loss, which may require adjustments to the TPN prescription.
A. TPN solutions must be administered according to the prescribed rate and schedule. Increasing the infusion rate without medical orders could lead to complications such as hyperglycemia or fluid overload.
D. TPN solutions are specifically formulated to meet the client's nutritional needs and cannot be substituted with other intravenous solutions like 0.9% sodium chloride.

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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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