A nurse is caring for an older client on a medical-surgical unit.Which of the following interventions should be included in the plan of care?
Monitor the client’s hydration status.
Encourage the client to engage in physical activities.
Administer medications as prescribed.
Educate the client on dietary needs.
The Correct Answer is A
Choice A rationale
Monitoring the client’s hydration status is critical for older adults, especially those on a medical-surgical unit, to prevent dehydration, which can lead to serious complications such as renal impairment, confusion, and electrolyte imbalance.
Choice B rationale
Encouraging physical activities is beneficial but is not always feasible or safe for all older clients, especially those with certain medical conditions or mobility limitations.
Choice C rationale
Administering medications as prescribed is essential but is a standard practice for all clients and not specific to older adults' unique needs.
Choice D rationale
Educating the client on dietary needs is important but secondary to monitoring hydration, which addresses more immediate physiological needs and complications.
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Correct Answer is D
Explanation
Choice A rationale
Inserting an indwelling catheter is not recommended for immunosuppressed clients due to the increased risk of infection. Minimizing invasive procedures is critical in these patients.
Choice B rationale
Providing fresh fruit is not advisable for immunosuppressed clients, as raw fruits and vegetables can harbor bacteria and increase the risk of infection. Cooked foods are safer options.
Choice C rationale
Taking the client's temperature once per shift is insufficient for monitoring infection in immunosuppressed clients. More frequent temperature monitoring is necessary to detect early signs of infection.
Choice D rationale
Limiting the number of health care workers entering the room is essential for reducing the risk of infections in immunosuppressed clients, as it minimizes exposure to potential pathogens.
Correct Answer is B
Explanation
Choice A rationale
An RBC count of 5 million/mm³ is within the normal range for adult females, so this finding would not be concerning in the context of chemotherapy.
Choice B rationale
A WBC count of 2300/mm³ is significantly lower than the normal range (typically 4500 to 11000/mm³) and indicates neutropenia, which is a critical side effect of chemotherapy that needs to be reported immediately.
Choice C rationale
Hemoglobin level of 12 g/dL is within the normal range for adult females, so this would not be concerning in the context of chemotherapy.
Choice D rationale
A platelet count of 155,000/mm³ is within the normal range (150,000 to 450,000/mm³). Although on the lower end, it is not typically alarming enough to report immediately in the context of chemotherapy.
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