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 A

Explanation

A. This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B. This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C. This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D. This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C. A mother and their newborn 12 hr postdelivery D. A client who has lower extremity weakness and is newly admitted for observation

Correct Answer is A

Explanation

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.

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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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