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 C
Explanation
- A. Incorrect. The nurse should assess the client's IV site every hour to prevent infection and phlebitis.
- B. Incorrect. The nurse should check the client's WBC count every day to monitor for signs of infection or bone marrow suppression.
- C. Correct. The nurse should monitor the client's mouth every 8 hr for signs of oral candidiasis, which is a common fungal infection in immunosuppressed clients.\
- D. Incorrect. The nurse should change the client's IV tubing every 24 hr to reduce the risk of bacterial contamination.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should include the information about keeping mobile phones at least 4 inches away from the pacemaker generator in the educational materials for the client. This is because mobile phones emit electromagnetic signals that could interfere with the functioning of the pacemaker. Maintaining a safe distance helps prevent electromagnetic interference, ensuring the pacemaker functions properly without any disruptions. It's crucial for the client to be aware of this to prevent potential complications and ensure the pacemaker's effectiveness.
Choice B rationale:
Limiting strenuous physical activity for 8 weeks is not a necessary precaution for a client with a new pacemaker unless specifically advised by the healthcare provider. Patients with pacemakers are often encouraged to resume normal activities after the procedure, with the understanding that they should listen to their bodies and avoid activities that cause discomfort or strain. There is no standard guideline suggesting an 8-week restriction on strenuous physical activity for all patients with new pacemakers.
Choice C rationale:
Checking the pulse rate for 30 seconds at different times throughout the day is a general health practice and not specifically related to the presence of a pacemaker. While monitoring heart rate is essential for overall health, it is not a pacemaker-specific guideline that must be included in the educational materials for a client with a new pacemaker.
Choice D rationale:
Expecting to have intermittent, prolonged hiccups is not relevant information for a client with a new pacemaker. Hiccups are a common physiological phenomenon and are not influenced by the presence of a pacemaker. Including this information in the educational materials would be irrelevant and potentially confusing for the client.
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