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.

Answer and Explanation

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.

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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.

A. Apply a tourniquet just below the elbow. B. Elevate the limb and apply ice. C. Clean the wound. D. Apply pressure above the wound.

Correct Answer is B

Explanation

Choice A reason: Applying a tourniquet just below the elbow is not recommended as the first line of action for a deep laceration unless there is life-threatening hemorrhaging that cannot be controlled by direct pressure. Tourniquets are used as a last resort because they can cause tissue damage.

Choice B reason: Elevating the limb and applying ice can help reduce bleeding and swelling. Elevation uses gravity to help reduce blood flow to the injury, and the cold from the ice constricts blood vessels, further helping to control bleeding and reduce swelling.

Choice C reason: Cleaning the wound is important, but it should not be the first action taken. The initial focus should be on stopping the bleeding. Once bleeding is controlled, the wound can be cleaned to prevent infection.

Choice D reason: Applying pressure directly to the wound with a clean cloth or bandage is the first step in controlling bleeding. However, the question specifies applying pressure above the wound, which would not be effective in controlling bleeding from the wound itself.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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