A nurse is caring for a client who has a white blood cell (WBC) count of 15,000/mm3. Which of the following actions should the nurse take?
Place the client in a private room.
Monitor the client's temperature every 4 hr.
Administer an antihistamine as prescribed.
Encourage the client to increase fluid intake.
The Correct Answer is B
Choice A reason: Placing the client in a private room is not necessary for a client who has a high WBC count, unless they have other indications for isolation, such as an infectious disease. A high WBC count may indicate inflammation, infection, or other conditions that affect the immune system.
Choice B reason: Monitoring the client's temperature every 4 hr is an appropriate action for a nurse to take for a client who has a high WBC count. A fever is a common sign of infection or inflammation, and it may require further intervention, such as antibiotics or antipyretics.
Choice C reason: Administering an antihistamine as prescribed is not related to a high WBC count. Antihistamines are used to treat allergic reactions, which may cause a low WBC count due to the release of histamine from mast cells.
Choice D reason: Encouraging the client to increase fluid intake is not specific to a high WBC count. Fluid intake should be based on the client's hydration status, urine output, and other factors. Increasing fluid intake may help flush out toxins or bacteria, but it is not a priority action for a client who has a high WBC count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is a contraindication for the MMR immunization, which is a live attenuated vaccine. A child who has a congenital immunodeficiency may not be able to mount an adequate immune response to the vaccine and may be at risk of developing the diseases from the vaccine.
Choice B reason: This is not a contraindication for the MMR immunization. A mild fever after a previous immunization is not a sign of an allergic reaction or a serious adverse effect. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.
Choice C reason: This is not a contraindication for the MMR immunization. Taking antibiotics for otitis media does not interfere with the effectiveness or safety of the vaccine. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.
Choice D reason: This is not a contraindication for the MMR immunization. A mild cough and a low-grade fever are not signs of a moderate or severe illness that would prevent the child from receiving the vaccine. The child can still receive the MMR immunization as long as they do not have any other contraindications.
Correct Answer is A
Explanation
Choice A reason: Encouraging the child to avoid sharing hats with other children is a preventive measure to reduce the risk of lice transmission. Lice are spread by direct contact with the hair or personal items of an infested person. Hats, combs, brushes, scarves, and pillows are some of the items that can harbor lice.
Choice B reason: The lice can survive for 2 weeks away from the host is a false statement. Lice cannot live longer than 24 to 48 hours without a human host. They need blood to survive and reproduce. Therefore, this information is not helpful for the parents to prevent or treat lice.
Choice C reason: Washing your child's hair daily will prevent lice is a false statement. Lice are not a sign of poor hygiene or cleanliness. They can affect anyone regardless of how often they wash their hair. In fact, lice may prefer clean hair because it is easier to attach to. Therefore, this information is not helpful for the parents to prevent or treat lice.
Choice D reason: Lice can jump from one child to another is a false statement. Lice cannot jump, fly, or hop. They can only crawl from one person to another. Therefore, this information is not helpful for the parents to prevent or treat lice.
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