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.
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Naxlex Comprehensive Predictor Exams
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Explanation
Choice A rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation).
Choice B rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation). It then decreases steadily at approximately 1 cm every 24 hours.
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Explanation
Choice A rationale:
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Choice B rationale:
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Choice C rationale:
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Choice D rationale:
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