A nurse is planning care for a client who has leukemia and is prescribed bed rest. Which of the following interventions should the nurse include in the plan?
Have the client perform pulmonary hygiene every 8 hr.
Place the client on airborne precautions.
Turn the client every 4 hr and apply powder to moist areas.
Assess the client's urine for odor and cloudiness.
The Correct Answer is D
- Rationale for Choice A: Pulmonary hygiene is important for preventing pneumonia, especially in bedridden clients. However, it is not specific to the care of a client with leukemia unless they have a respiratory complication which necessitates such an intervention.
- Rationale for Choice B: Airborne precautions are typically used for clients who have infections that can be transmitted through the air, such as tuberculosis. Leukemia does not require airborne precautions unless the client has a coexisting airborne infection.
- Rationale for Choice C: Regular turning of the client can help prevent pressure ulcers and is a good practice for any bedridden patient. However, the use of powder is controversial as it can cake and lead to skin breakdown, and is not specifically indicated for leukemia care.
- Rationale for Choice D: Assessing the client's urine for odor and cloudiness is an important part of care for clients with leukemia. They are at increased risk for urinary tract infections due to immunosuppression, and changes in urine can indicate an infection that needs prompt treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Rapid mood swings are not a defining characteristic of major depressive disorder.
Choice B rationale:
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
Choice C rationale:
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
Choice D rationale:
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
Correct Answer is B
Explanation
Choice A rationale:
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
Choice B rationale:
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
Choice C rationale:
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
Choice D rationale:
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.