A nurse is caring for a 60-year-old female client in the oncology unit who is currently receiving chemotherapy for breast cancer. The client presents with a recent onset of symptoms, and the nurse must evaluate the best actions to take based on the exhibits provided.
Which of the following actions should the nurse take?
Place the client on contact precautions.
Place the client in a private room.
Encourage the client to increase fluid intake.
Wear a mask when caring for the client.
Prepare to administer an antibiotic to the client.
Correct Answer : B,C,D
Choice A rationale: Contact precautions are not necessary in this situation as the client is presenting symptoms of a possible infection related to chemotherapy-induced immunosuppression, not a contagious disease.
Choice B rationale: Placing the client in a private room is crucial to protect her from potential infections, given her compromised immune system due to chemotherapy.
Choice C rationale: Encouraging the client to increase fluid intake can help manage fever and muscle aches and keep her hydrated, which is important when dealing with symptoms of infection and fatigue.
Choice D rationale: Wearing a mask when caring for the client is necessary to protect both the client and the healthcare provider from potential infections, considering the client’s immunocompromised state.
Choice E rationale: Preparing to administer an antibiotic should be based on the healthcare provider's orders and further diagnostic results. While it might be necessary, it is not an immediate nursing action without provider confirmation.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Inserting an indwelling catheter is not recommended for immunosuppressed clients due to the increased risk of infection. Minimizing invasive procedures is critical in these patients.
Choice B rationale
Providing fresh fruit is not advisable for immunosuppressed clients, as raw fruits and vegetables can harbor bacteria and increase the risk of infection. Cooked foods are safer options.
Choice C rationale
Taking the client's temperature once per shift is insufficient for monitoring infection in immunosuppressed clients. More frequent temperature monitoring is necessary to detect early signs of infection.
Choice D rationale
Limiting the number of health care workers entering the room is essential for reducing the risk of infections in immunosuppressed clients, as it minimizes exposure to potential pathogens.
Correct Answer is A
Explanation
Choice A rationale
Exercise, in general, is beneficial and should not exacerbate systemic lupus erythematosus (SLE). In fact, regular, gentle exercise can improve overall health and reduce symptoms.
Choice B rationale
Infection can trigger or exacerbate SLE flares by activating the immune system, which can cause increased inflammation.
Choice C rationale
Sunlight exposure can exacerbate SLE due to photosensitivity, leading to skin rashes and triggering systemic flares.
Choice D rationale
Pregnancy can exacerbate SLE due to hormonal changes and the additional strain on the immune system.
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