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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.
The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.
Correct Answer is B,A,C,D
Explanation
The nurse should first check for contraindications to tPA, such as hemorrhagic stroke, recent surgery, bleeding disorder, or uncontrolled hypertension. Then, the nurse should weigh the client to calculate the correct dose of tPA based on body weight. Next, thenurse should administer the tPA within three hours of symptom onset to improve the chances of recovery. Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and possible complications.
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