A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?
Administer a saline enema for constipation.
Initiate contact precautions.
Encourage independence in the completion of ADLs.
Monitor oral mucosa daily.
The Correct Answer is D
A. Administer a saline enema for constipation. Administering a saline enema may be necessary for constipation, but it is not directly related to managing bone marrow suppression.
B. Initiate contact precautions. Contact precautions are typically used for infectious diseases. In clients with bone marrow suppression, neutropenic precautions are more appropriate to prevent infections.
C. Encourage independence in the completion of ADLs. While promoting independence is important, clients with bone marrow suppression may be fatigued or immunocompromised, requiring assistance to reduce infection risk and conserve energy.
D. Monitor oral mucosa daily. Monitoring oral mucosa daily is crucial because clients with bone marrow suppression are at risk for mucositis, which can lead to infection and impact nutrition and hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Offer the client fluids with meals. Offering fluids with meals may decrease the client's appetite by creating a sense of fullness, which could further reduce calorie intake and not aid in weight gain.
B. Increase fiber in the client's diet. While fiber is important for digestive health, it may also contribute to a feeling of fullness and might not directly help in increasing body weight in clients with anorexia.
C. Encourage the client to eat less protein. Protein is essential for maintaining muscle mass and overall health, especially in clients with AIDS. Reducing protein intake would not be beneficial for weight gain or health maintenance.
D. Provide supplemental vitamins and supplemental nutrition. Offering supplemental nutrition and vitamins can help increase caloric intake and ensure that the client receives essential nutrients to support weight gain and overall health. This is the most appropriate action to help increase the client's body weight.
Correct Answer is ["A","C","D"]
Explanation
A. Unequal pupils: Unequal pupils (anisocoria) can indicate a potential neurological issue, such as intracranial pressure or brain injury, especially after trauma. It is a significant finding requiring further evaluation.
B. Pupil reaction quick: Quick pupil reaction is typically normal and indicates proper neurological function, not a concern.
C. Pinpoint pupils: Pinpoint pupils can indicate opioid overdose or certain types of brainstem injury and should be evaluated as a potential neurological concern.
D. Absence of pupillary response: Absence of pupillary response to light can be a serious neurological concern, indicating severe brain injury or significant neurological compromise.
E. Pupil reacts to light: A pupil that reacts to light is a normal finding and indicates proper neurological function.
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