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:
Increasing fiber intake is a key recommendation for managing diverticulosis.
Choice B rationale:
Cellulose-containing foods, such as whole grains and vegetables, are important sources of dietary fiber and are encouraged for managing diverticulosis.
Choice C rationale:
Stimulating laxatives are not recommended for managing diverticulosis and could potentially exacerbate symptoms.
Choice D rationale:
Limiting fat intake to 30% or less is a dietary recommendation for managing diverticulosis. A high-fiber diet is also important to prevent diverticular inflammation.
Correct Answer is D
Explanation
Choice A rationale:
Replacing the ritual with a different ritualistic behavior is possible, but it does not necessarily predict the initial response when the restriction is first imposed.
Choice B rationale:
Reporting auditory hallucinations is not a typical response to restricting ritualistic behavior in someone with OCD.
Choice C rationale:
Expressing relief from not having to perform the ritual is unlikely, as ritualistic behaviors in OCD are often driven by distress and anxiety.
Choice D rationale:
If ritualistic behavior is restricted in an individual with obsessive- compulsive disorder (OCD), they may experience panic-level anxiety due to their inability to engage in their usual coping mechanism. OCD rituals are often performed to reduce anxiety, and restricting them can lead to increased distress.
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