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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?

A.

Avoid including raw fruits in the client's diet.

B.

Restrict visits from young children to 2 hr per day.

C.

Measure the client's temperature once per shift.

D.

Use disposable gloves from a box outside the client's room.

Answer and Explanation

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. 


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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

Almonds are not typically associated with latex allergy or cross-sensitivity. Latex cross-reactivity is more commonly seen with certain fruits such as bananas, avocados, kiwis, and chestnuts.

Choice B rationale:

Bananas are known to be cross-reactive with latex allergy. Individuals allergic to latex are more likely to have allergies to certain fruits, including bananas. This cross-sensitivity occurs due to the structural similarity between latex proteins and proteins found in these fruits.

Choice C rationale:

Hazelnuts are not commonly associated with latex cross-reactivity. While some individuals with latex allergy may also be allergic to hazelnuts, it is not a high-risk food in the context of latex cross-sensitivity.

Choice D rationale:

Strawberries are not typically associated with latex allergy or cross-reactivity. Latex cross-reactivity is more commonly seen with fruits like bananas, avocados, kiwis, and chestnuts. Strawberries are not among the high-risk foods for individuals with latex allergy.

Correct Answer is B

Explanation

Aspirate contents from the tube and verify the pH level.

  • A. This is an incorrect action. Inserting air in the tube and listening for gurgling sounds in the epigastric area is not a reliable method to confirm NG tube placement, as it can produce falsepositive results due to air entering the stomach or intestines.
  • B. This is a correct action. Aspirating contents from the tube and verifying the pH level is a valid method to confirm NG tube placement, as gastric contents typically have a pH of less than 5.5, while intestinal or respiratory contents have a higher pH.
  • C. This is an incorrect action. Reviewing the medical record for previous x-ray verification of placement is not sufficient to confirm NG tube placement, as the tube can migrate or become dislodged after insertion. X-ray verification should be done initially and whenever there is doubt about the tube's position.
  • D. This is an incorrect action. Auscultating the lungs for adventitious breath sounds is not a specific method to confirm NG tube placement, as it can indicate other conditions such as pneumonia or pulmonary edema. It can also miss signs of respiratory complications due to NG tube misplacement, such as pneumothorax or bronchial obstruction.

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