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.

Answer and Explanation

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 C

Explanation

Choice A rationale
Examining the client for hepatomegaly can be part of a broader assessment but does not directly address the fatigue related to chemotherapy, particularly cisplatin, which is known to cause bone marrow suppression.
Choice B rationale
Assessing for a hypersensitivity reaction is important during chemotherapy, but it does not specifically address the issue of fatigue, which is often related to blood cell counts.
Choice C rationale
Checking the results of the client's most recent CBC (complete blood count) is crucial because cisplatin can cause anemia, leukopenia, and thrombocytopenia, all of which can lead to significant fatigue.
Choice D rationale
Evaluating for hypercalcemia is not typically associated with cisplatin treatment; it is more relevant in malignancies associated with bone metastasis or overproduction of parathyroid hormone-related protein.

A. Platelets. B. Calcium. C. Absolute neutrophil count (ANC). D. White blood cells (WBCs).

Correct Answer is B

Explanation

Choice A rationale
Metastatic bone cancer does not typically result in an increase in platelet count. Platelets are involved in blood clotting, and their levels are not usually affected by bone metastases.
Choice B rationale
Calcium levels are often increased in clients with metastatic bone cancer due to the breakdown of bone tissue releasing calcium into the bloodstream.
Choice C rationale
Absolute neutrophil count (ANC) is not typically increased in metastatic bone cancer. ANC levels are more directly related to infections and bone marrow function.
Choice D rationale
White blood cell (WBC) count is not typically increased in metastatic bone cancer. Elevated WBC levels are more commonly associated with infection or inflammation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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