A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take?

Instruct the client to avoid eating raw fruit.

Use contact isolation while providing care.

Apply pressure to venipuncture sites for 10 min.

Move the client to a negative pressure room.

Answer and Explanation

The Correct Answer is A

The client has neutropenia, which is a low number of neutrophils, a type of white blood cell that fights infection. The client is at risk for developing infections from bacteria and fungi that are normally present in the environment. Raw fruits may contain these microorganisms and should be avoided.

Contact isolation is not necessary for neutropenic clients, unless they have an active infection. Applying pressure to venipuncture sites for 10 min is a standard precaution for all clients, not specific to neutropenic clients. Moving the client to a negative pressure room is indicated for clients with airborne infections, not neutropenic clients.

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Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: This choice suggests that the provider will prescribe a different medication regimen. However, this is not necessarily the case. Rifampin is a first-line medication for tuberculosis and its side effects, including the discoloration of body fluids, are well-known and expected. Therefore, it is unlikely that the provider would change the medication regimen solely based on this side effect.

Choice B rationale: This is the correct answer. Rifampin, an antibiotic used to treat tuberculosis, can cause a harmless red-orange discoloration of body fluids, including urine, sweat, tears, and saliva. This is an expected side effect of the medication and does not indicate any harm or toxicity. It is important for the nurse to reassure the client that this is a normal occurrence and does not require any changes to the medication regimen.

Choice C rationale: This choice suggests that the red-orange discoloration of the client’s saliva may indicate possible medication toxicity. However, this is not accurate. While rifampin can have serious side effects, including liver damage and severe gastrointestinal upset, the discoloration of body fluids is not a sign of toxicity. It is a harmless side effect of the medication.

Choice D rationale: This choice suggests that the client will need to increase her fluid intake to resolve the problem. However, increasing fluid intake will not change the discoloration caused by rifampin. The discoloration is a result of the medication itself and is not influenced by the client’s hydration status.

A. Confusion B. Blurred vision C. Diarrhea D. Polyuria

Correct Answer is A

Explanation

Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.

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A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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