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 C
Explanation
Choice A rationale
Providing a low-carbohydrate diet is not appropriate for a client in Addisonian crisis. Addisonian crisis requires immediate treatment with corticosteroids, not dietary changes.
Choice B rationale
Weighing the client daily is important for monitoring fluid balance, but it is not the primary action during an Addisonian crisis. The priority is to correct the hormonal imbalance.
Choice C rationale
Administering oral corticosteroids is crucial for treating Addisonian crisis. It helps replace the deficient adrenal hormones and manage the crisis effectively.
Choice D rationale
Restricting fluid intake is not recommended during an Addisonian crisis. Clients in crisis may need fluid replacement to manage dehydration and hypotension.
Correct Answer is C
Explanation
Choice A rationale
Systemic lupus erythematosus (SLE) does not originate in the peripheral vascular system. This system involves the blood vessels outside of the heart and brain, and while SLE can affect these vessels, it is not the primary origin of the disease.
Choice B rationale
SLE does not originate in muscle tissue. Muscle involvement in SLE typically results from inflammation caused by the autoimmune response, but muscle tissue is not the source of the disease.
Choice C rationale
Connective tissue is where SLE originates. SLE is an autoimmune disease that primarily targets connective tissue, causing inflammation and damage to various organs and systems throughout the body.
Choice D rationale
The lymphatic system is not the origin of SLE. While the immune system plays a key role in SLE, the disease itself originates in the connective tissue, not the lymphatic system.
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