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.

Answer and Explanation

The Correct Answer is A

A. Correct. The nurse should avoid including raw fruits in the client's diet because they can harbor bacteria and fungi that can cause infection in a client who has neutropenia, which is a low white blood cell count.

B. Incorrect. The nurse should limit visits from anyone who is sick or has been exposed to an infection, but there is no need to restrict visits from young children specifically, as long as they are healthy and follow proper hand hygiene.

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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Correct Answer is D

Explanation

A. This is incorrect because weight gain is not expected in clients who have COPD, as they often have difficulty eating and digesting food due to dyspnea and fatigue.
B. This is incorrect because a decrease in anteroposterior diameter of the chest is not typical of COPD, as the condition causes hyperinflation and air trapping in the lungs, leading to an increase in chest size and a barrel-shaped appearance.
C. This is incorrect because HCO3 24 mEq/L is within the normal range for blood bicarbonate levels, which are 22 to 26 mEq/L. Clients who have COPD often have chronic respiratory acidosis, which stimulates the kidneys to retain bicarbonate and increase its levels in the blood to compensate for the low pH.
D. This is correct because pH 7.31 indicates acidosis, which is common in clients who have COPD due to impaired gas exchange and accumulation of carbon dioxide in the blood.

A. "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" C. "Part of recovery is accepting your new body image, and you will need to look at your incision." D. "You will feel beter when you see that the incision is not as bad as you may think."

Correct Answer is A

Explanation

- A mastectomy is a surgical procedure that involves the removal of all or part of the breast, usually to treat breast cancer. A mastectomy can have a significant impact on a woman's physical, emotional, and psychological well-being, as it may aﬀect her body image, self-esteem, sexuality, and identity.
- A mastectomy incision is the wound that results from the surgery, which may vary in size, shape, and location depending on the type and extent of the mastectomy. The incision may be closed with stitches, staples, or glue, and covered with a dressing or bandage.

- The first dressing change is usually done within 24 to 48 hours after the surgery, and it involves removing the old dressing, inspecting the incision for any signs of infection or complications, cleaning the wound, applying a new dressing, and educating the client about wound care .
- When the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it, this may indicate that the client is experiencing denial, fear, anger, grief, or depression due to the loss of her breast. These are normal and common reactions that may occur at diﬀerent stages of the recovery process .
- The best response by the PN to the client's silence is to acknowledge and respect the client's feelings, provide support and reassurance, and oﬀer assistance when needed. This will help to establish trust and rapport with the client, as well as promote her coping and adjustment .
- Therefore, option A is the best answer, as it shows empathy and respect for the client's feelings, while also informing the client that the PN will be available when she is ready to look or talk about the mastectomy. Option A also implies that the PN will not pressure or force the client to do something that she is not comfortable with.

- Options B, C, and D are incorrect answers, as they do not show empathy or respect for the client's
feelings, and they may cause more harm than good.
Option B is incorrect because asking another nurse to be present may not address the client's reluctance or
anxiety about looking at her incision.
Option C is incorrect because telling the client that part of recovery is accepting her new body image may
sound insensitive or judgmental, and it may not reﬂect the client's readiness or willingness to do so.
Option D is incorrect because telling the client that she will feel beter when she sees that the incision is not as bad as she may think may minimize or invalidate the client's feelings, and it may not be true or helpful.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

Correct Answer is A

Explanation

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