A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm.
Which of the following actions should the nurse take?
Apply pressure to venipuncture sites for 10 min.
Move the client to a negative pressure room.
Instruct the client to avoid eating raw fruit.
Use contact isolation while providing care.
The Correct Answer is C
Instruct the client to avoid eating raw fruit.
A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection.
One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
Choice D Contact isolation while providing care is not necessary for a low WBC count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Correct Answer is D
Explanation
The nurse should ask the client to empty his bladder prior to the procedure.
This is important because a full bladder can obstruct the area where the needle will be inserted and increase the risk of bladder injury during the procedure.
Choice A is incorrect because the client should be positioned sitting upright or lying in bed with the head of the bed elevated during the procedure.
Choice B is incorrect because administering a stool softener is not necessary following an abdominal paracentesis.
Choice C is incorrect because the client should be instructed to exhale and hold their breath during needle insertion to help move the diaphragm upward and away from the area where the needle will be inserted.
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