A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Limit the number of health care workers entering the room.

Insert an indwelling catheter to monitor for sediment in the urine.

Take the client’s temperature once per shift

Provide the client with fresh fruit to avoid constipation

Answer and Explanation

The Correct Answer is A

A.   Limiting the number of health care workers entering the room helps reduce the risk of exposure to infections.
B.   Inserting an indwelling catheter is not a routine intervention for immunosuppressed clients and may increase the risk of infection.
C.   Monitoring temperature more frequently than once per shift is crucial to detect early signs of infection in immunosuppressed clients.
D.   Fresh fruit may carry a risk of bacterial contamination, and caution should be exercised in providing it to immunosuppressed clients.

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Correct Answer is D

Explanation

A. Creatine kinase is an enzyme associated with muscle damage, not an indicator of infection.
B. Hemoglobin (Hgb) measures the amount of oxygen-carrying pigment in the blood and is not specific to infection.
C. Platelet count reflects the number of platelets in the blood and is not a direct indicator of infection.
D. An elevated white blood cell (WBC) count is indicative of an immune system response to infection.

A. Non-palpable spleen B. Rough, dry skin. C. Presence of surface papillae on tongue D. Slightly moist skin

Correct Answer is B

Explanation

A. Non-palpable spleen is not a typical manifestation of malnutrition but may be associated with other health conditions.
B. Rough, dry skin is a common manifestation of malnutrition, reflecting deficiencies in essential nutrients affecting skin health.
C. The presence of surface papillae on the tongue is not specifically associated with malnutrition.
D. Slightly moist skin is less likely in malnutrition; dry skin is more characteristic.

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A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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