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 ["B"]
Explanation
Choice A reason: Polyuria, or excessive urination, is not a sign of low blood glucose level, but of high blood glucose level. It is caused by osmotic diuresis, which occurs when the kidneys try to flush out the excess glucose from the blood.
Choice B reason: Tachycardia, or fast heart rate, is a sign of low blood glucose level. It is caused by the activation of the sympathetic nervous system, which releases adrenaline and other hormones to increase the blood glucose level and stimulate the heart.
Choice C reason: Dry, flushed skin is not a sign of low blood glucose level, but of high blood glucose level. It is caused by dehydration, which occurs when the body loses fluid due to polyuria and increased thirst.
Choice D reason: Deep, rapid respirations are not a sign of low blood glucose level, but of diabetic ketoacidosis, a complication of high blood glucose level. It is caused by the accumulation of ketones, which are acidic substances produced when the body breaks down fat for energy due to lack of insulin.
Choice E reason: Hunger is a sign of low blood glucose level. It is caused by the lack of glucose in the cells, which are the main source of energy for the body. The brain signals the body to eat more to raise the blood glucose level.
Correct Answer is C
Explanation
Choice A reason: Continuing to monitor the client is not the best action, as it does not address the low urine output of the child. The child has a urine output of 20 mL/hr, which is below the expected range of 30 to 40 mL/hr for a 3-year-old child. Low urine output can indicate dehydration, kidney injury, or urinary tract obstruction, which require prompt intervention.
Choice B reason: Performing a bladder scan at the bedside is not the most appropriate action, as it is not the first-line diagnostic tool for low urine output. A bladder scan is a noninvasive ultrasound device that measures the amount of urine in the bladder. It can help detect urinary retention, which is the inability to empty the bladder completely. However, urinary retention is unlikely in a 3-year-old child, and a bladder scan may not be accurate or reliable in children.
Choice C reason: Providing oral rehydration fluids is the best action, as it can help restore the fluid and electrolyte balance of the child. Oral rehydration fluids are solutions that contain water, sugar, and salt in specific proportions that match the body's needs. They can prevent or treat dehydration, which is a common cause of low urine output in children. The nurse should offer the child oral rehydration fluids every 15 to 20 minutes, and monitor the urine output, vital signs, and hydration status.
Choice D reason: Notifying the provider is not the first action, as it is not the most urgent or effective intervention for low urine output. The nurse should notify the provider after providing oral rehydration fluids and assessing the child's response. The nurse should also report any signs or symptoms of dehydration, such as dry mucous membranes, sunken eyes, poor skin turgor, or lethargy. The provider may order further tests or treatments, such as blood tests, urine tests, or intravenous fluids.
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