A nurse is caring for an older adult client who has a WBC count of 2,000/mm after three rounds of chemotherapy. Which of the following actions should the nurse take?
Humidify the client's room.
Replace the water in flower vases with fresh water daily.
Clean dentures in a denture cup.
Serve cooked fruit with meals.
The Correct Answer is D
Choice A reason: Humidifying the client's room can help maintain mucous membrane integrity and prevent respiratory infections, which is crucial for a client with a low WBC count.
Choice B reason: Replacing the water in flower vases daily can prevent the growth of bacteria, reducing the risk of infection for an immunocompromised client.
Choice C reason: Cleaning dentures in a denture cup is a standard infection control practice that helps maintain oral hygiene and prevent infections.
Choice D reason: Serving cooked fruit with meals reduces the risk of transmitting infections that can be associated with raw fruits, which is important for a client with neutropenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: An oral temperature of 38.2°C (100.76°F) is slightly elevated but can be expected postoperatively as the body responds to surgical stress. It is not necessarily an indication of a complication unless it rises significantly or is accompanied by other symptoms.
Choice B reason: The output of burgundy colored urine can indicate bleeding in the urinary tract, which is a potential complication after TURP. Normal urine color ranges from pale yellow to deep amber, depending on hydration levels. Burgundy colored urine postTURP could suggest the presence of blood, warranting further assessment and intervention.
Choice C reason: Feeling an urge to void despite having an indwelling urinary catheter can be uncomfortable but is not uncommon after TURP due to irritation of the bladder. It is not typically a sign of a complication unless accompanied by other symptoms such as pain or difficulty urinating once the catheter is removed.
Choice D reason: A pulse rate of 58/min is within the normal resting range for adults, which is typically 60100 beats per minute. A lower than average pulse rate postoperatively might be normal for the patient, especially if they are on medications like betablockers, or it could be a sign of a good fitness level.
Correct Answer is C
Explanation
Choice A reason: Fatigue is a common symptom of ITP but is not the primary concern for monitoring, as it does not directly indicate the severity of the condition.
Choice B reason: While monitoring for side effects of immunosuppressants is important, it is not the priority concern. The primary issue in ITP is the low platelet count, which poses a risk of bleeding.
Choice C reason: Thrombocytopenia, or low platelet count, is the hallmark of ITP and the main concern for monitoring, as it increases the risk of bleeding and bruising.
Choice D reason: Infection is a risk due to the potential use of immunosuppressants in treatment; however, the immediate concern in ITP management is the platelet count and associated bleeding risk.
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