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: The posterior fontanel, which is the soft spot at the back of the infant's head, normally closes by 2 to 4 months of age. Therefore, the nurse should expect to find a closed posterior fontanel in a 6-month-old infant.
Choice B reason: Lateral incisors, which are the teeth on either side of the central incisors, normally erupt between 7 and 10 months of age. Therefore, the nurse should not expect to find lateral incisors in a 6-month-old infant.
Choice C reason: Sitting steadily without support is a developmental milestone that is usually achieved between 6 and 9 months of age. Therefore, the nurse may or may not expect to find this skill in a 6-month-old infant, depending on the individual variation.
Choice D reason: Using thumb and index fingers in a pincer grasp is a fine motor skill that is usually developed between 9 and 12 months of age. Therefore, the nurse should not expect to find this skill in a 6-month-old infant.
Correct Answer is D
Explanation
Choice A reason: Tetany is not a typical finding in an infant who is dehydrated. Tetany is a condition where the muscles contract involuntarily and cause spasms or cramps. It is usually caused by low calcium levels or alkalosis, not dehydration.
Choice B reason: Slow, bounding pulse is not a typical finding in an infant who is dehydrated. A slow, bounding pulse may indicate increased intracranial pressure or heart failure, not dehydration. A fast, weak pulse is more likely to occur in an infant who is dehydrated.
Choice C reason: Decreased temperature is not a typical finding in an infant who is dehydrated. A decreased temperature may indicate hypothermia or sepsis, not dehydration. A normal or slightly elevated temperature is more likely to occur in an infant who is dehydrated.
Choice D reason: Irritability is a typical finding in an infant who is dehydrated. Irritability indicates that the infant is uncomfortable and thirsty. It may also be a sign of cerebral dehydration, which can affect the infant's mental status and behavior.
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