A nurse is caring for a client.

Nurses Notes: Day 1: Custom Nursing Assessment.

Vital Signs: Diagnostic Results: Client is admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.

Prepare to administer an antibiotic to the client.

Which of the following actions should the nurse take? (Select all that apply.)

Encourage the client to increase fluid intake.

Place the client in a private room.

Place the client on contact precautions.

Wear a mask when caring for the client.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale
Encouraging the client to increase fluid intake is correct. Increasing fluid intake helps to maintain hydration, which is essential for the body to function properly, especially when the client is experiencing fever and muscle aches. Hydration helps to thin mucus, making it easier to expel, and supports the immune system in fighting off infection.
Choice B rationale
Placing the client in a private room is correct. A private room helps to prevent the spread of infection to other patients and healthcare workers. This is particularly important when the client has symptoms such as fever, sore throat, and fatigue, which could indicate a contagious illness.
Choice C rationale
Placing the client on contact precautions is incorrect. Contact precautions are typically used for infections that are spread by direct contact with the patient or their environment, such as MRSA or C. difficile. The symptoms described (headache, muscle aches, fever, sore throat, and fatigue) do not necessarily indicate an infection that requires contact precautions.
Choice D rationale
Wearing a mask when caring for the client is correct. Wearing a mask helps to prevent the transmission of respiratory infections, which can be spread through droplets when the client coughs or sneezes. This is especially important when the client has symptoms such as a sore throat and fever, which could indicate a respiratory infection.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale
The client has an increased risk for bleeding. Cisplatin is a chemotherapy drug that can cause myelosuppression, leading to a decrease in platelets (thrombocytopenia). However, the client’s platelet count is 170,000/mm³, which is within the normal range (150,000-450,000/mm³).
Therefore, the client does not have an increased risk for bleeding based on the current CBC results.
Choice B rationale
The client should receive an erythropoiesis stimulating agent. Cisplatin can cause anemia due to myelosuppression, which would be indicated by a low hemoglobin (Hgb) and hematocrit (Hct). However, the client’s Hgb is 12.1 g/dL and Hct is 36.5%, both of which are within normal limits (Hgb: 12-16 g/dL for females, Hct: 36-48% for females). Therefore, there is no immediate need for an erythropoiesis stimulating agent based on the current CBC results.
Choice C rationale
The client should receive a diet with increased protein. While a high-protein diet can be beneficial for cancer patients to help maintain muscle mass and support recovery, the CBC results do not indicate a specific need for increased protein intake. The client’s albumin level is 4.5 g/dL, which is within the normal range (3.5-5.0 g/dL), indicating adequate protein status.
Choice D rationale
The client has an increased risk of infection. Cisplatin can cause neutropenia, a condition characterized by a low white blood cell (WBC) count, which increases the risk of infection. The client’s WBC count is 1,400/mm³, which is significantly below the normal range (4,000- 11,000/mm³). This indicates severe neutropenia, putting the client at a high risk for infections. Therefore, it is crucial for the nurse to consider infection prevention measures for this client.

A. Include fluoridated water in the toddler’s diet. B. Administer fat-soluble vitamins daily. C. Limit intake of high-protein foods. D. Avoid a diet that consists primarily of milk.

Correct Answer is D

Explanation

Choice A rationale
Including fluoridated water in the toddler’s diet does not prevent iron deficiency anemia.
Choice B rationale
Administering fat-soluble vitamins daily is not a method of preventing iron deficiency anemia.
Choice C rationale
Limiting intake of high-protein foods is not related to preventing iron deficiency anemia.
Choice D rationale
Avoiding a diet that consists primarily of milk is recommended because excessive milk intake can interfere with iron absorption and lead to iron deficiency anemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client’s most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client?

Correct Answer is D

Explanation

A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?

Correct Answer is D

Explanation

A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hours. Which of the following categories of shock should the nurse recognize is occurring?

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?

A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin’s effects?

A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

A nurse is providing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include in the teaching to explain the correlation between changes in the coronary arteries and manifestations that occur?

A nurse is assessing a client who has a pneumothorax with a chest tube in place For which of the following findings should the nurse notify the provider?