A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?
Wear an N95 respirator.
Insert an indwelling urinary catheter to monitor urinary output.
Monitor the client's vital signs every 8 hr.
Use a dedicated stethoscope.
The Correct Answer is D
A. Wearing an N95 respirator is not necessary when caring for a client with neutropenia due to HIV unless the client has respiratory symptoms or is undergoing procedures that generate aerosols.
B. Inserting an indwelling urinary catheter should be avoided unless necessary, as it can
introduce the risk of infection, which is particularly concerning in clients with neutropenia.
C. Monitoring vital signs every 8 hours may not provide sufficient frequency for detecting changes in a client with neutropenia who may be at risk for rapid deterioration.
D. Using a dedicated stethoscope helps prevent the spread of infection to other clients by avoiding cross-contamination, which is especially important when caring for a client with neutropenia who is at increased risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.
B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.
C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.
D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.
Correct Answer is A
Explanation
A. Hypotension occurs because hypermagnesemia causes vasodilation, which lowers blood pressure. Magnesium acts as a smooth muscle relaxant, decreasing vascular resistance and contributing to hypotension. This is a common clinical finding when magnesium levels exceed the normal range.
B. Tachycardia is not expected with hypermagnesemia. Elevated magnesium levels depress the heart's electrical activity, leading to bradycardia (slow heart rate) instead of tachycardia.
C. Muscle cramps are typically associated with hypomagnesemia, which increases neuromuscular excitability. In hypermagnesemia, neuromuscular function is suppressed, leading to muscle weakness rather than cramps.
D. Hyperreflexia is a symptom of hypomagnesemia, not hypermagnesemia. In hypermagnesemia, neuromuscular activity is depressed, resulting in diminished or absent deep tendon reflexes
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