A nurse is planning care for a client who is receiving chemotherapy and has neutropenia.
Which of the following interventions should the nurse include in the plan?
Avoid including raw fruits in the client's diet.
Restrict visits from young children to 2 hr per day.
Measure the client's temperature once per shift.
Use disposable gloves from a box outside the client's room.
The Correct Answer is A
- A. The nurse should discourage raw fruits due to risk of infection.
- B. There is no standard recommendation against exposure to young children.
- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Correct answer: A, B, C, E
Rationale:
- A: Alternate eating solid foods and liquids is recommended. This can help prevent dehydration and malnutrition, as well as reduce the risk of vomiting by avoiding overfilling the stomach.
- B: Eat every 2 to 3 hr is recommended. This can help maintain blood glucose levels and prevent hunger-induced nausea.
- C: Drink warm ginger ale when nauseated is recommended. Ginger has antiemetic properties and can help soothe the stomach and reduce nausea.
- E: Recommended actions is correct. The nurse should indicate which actions are recommended for the client.
- D: Increase intake of high-fat foods is contraindicated. High-fat foods can delay gastric emptying and worsen nausea and vomiting. The client should eat low-fat, bland, and easy-todigest foods instead.
Correct Answer is C
Explanation
- a. The last time the provider evaluated the client:This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
- b. The client's most recent ventilator settings:The client's most recent ventilator settings (B) would no longer be relevant if the client has been successfully weaned off mechanical ventilation.
- c. The time of the client's last dose of pain medication:This helps manage the client's pain effectively and prevent potential withdrawal symptoms.
d. This information is not clinically relevant for the next nurse’s shift. While the frequency of call button use may reflect a client's needs or comfort level, it is not a priority for safe, evidence-based clinical care and does not impact the client’s medical treatment or condition.
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