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 C
Explanation
Choice A reason: A respiratory rate of 24 breaths/min is within the normal range for a 3-year-old child. It does not indicate the degree of hydration or dehydration of the child.
Choice B reason: A heart rate of 130/min is above the normal range for a 3-year-old child, which is 80 to 120/min. It may indicate dehydration, fever, pain, or anxiety. It does not indicate the effectiveness of oral rehydration therapy.
Choice C reason: A urine specific gravity of 1.015 is within the normal range for a child, which is 1.005 to 1.030. It indicates that the child's urine is adequately concentrated and that the child is well hydrated. It is a reliable indicator of the effectiveness of oral rehydration therapy.
Choice D reason: A capillary refill of greater than 3 seconds is abnormal and indicates poor peripheral perfusion. It may be a sign of dehydration, shock, or hypothermia. It does not indicate the effectiveness of oral rehydration therapy.
Correct Answer is A
Explanation
Choice A reason: This is the correct instruction for the nurse to include in the plan. Mumps is a viral infection that causes inflammation of the salivary glands. It is transmitted by respiratory droplets from coughing, sneezing, or talking. The nurse should initiate droplet precautions, which include wearing a surgical mask, gloves, and gown, and keeping the child in a private room or with other children who have mumps.
Choice B reason: This is not the correct instruction for the nurse to include in the plan. Airborne precautions are used for infections that are transmitted by small particles that can remain suspended in the air for long periods of time, such as tuberculosis, chickenpox, or measles. Mumps is not an airborne infection, and the nurse does not need to wear a respirator or place the child in a negative pressure room.
Choice C reason: This is not the correct instruction for the nurse to include in the plan. Contact precautions are used for infections that are transmitted by direct or indirect contact with the infected person or their environment, such as scabies, impetigo, or MRSA. Mumps is not a contact infection, and the nurse does not need to wear gloves and gown for all interactions with the child or use disposable equipment.
Choice D reason: This is not the correct instruction for the nurse to include in the plan. Standard precautions are the minimum level of infection control that should be used for all patients, regardless of their diagnosis or presumed infection status. They include hand hygiene, use of personal protective equipment, safe injection practices, and environmental cleaning. However, they are not sufficient for preventing the transmission of mumps, and the nurse should use additional precautions.
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