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. 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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Related Questions
Correct Answer is B
Explanation
A. Incorrect. Withholding pain medications for 24 hr after the old patch is removed is a harmful action that could cause severe withdrawal symptoms and uncontrolled pain for the client. The nurse should respect the client's right to refuse treatment and explore the reasons for their decision.
B. Correct. Asking another nurse to witness the disposal of the new patch is a safe and legal action that follows the policies and procedures for handling controlled substances. The nurse should document the disposal of the new patch and report it to the appropriate authority.
C. Incorrect. Sealing the patches in a plastic bag and placing them in the client's trash basket is an unsafe and illegal action that could lead to diversion, misuse, or accidental exposure of fentanyl to others. The nurse should dispose of the patches in a secure and designated container that prevents access by unauthorized persons.
D. Incorrect. Sticking the two patches to each other and placing them in the sharps bin is an unsafe and improper action that could cause contamination, injury, or infection to others who handle or dispose of sharps waste. The nurse should dispose of the patches separately and carefully, avoiding contact with their adhesive surfaces.
Correct Answer is C
Explanation
A is incorrect because it is an example of self-disclosure, not altruism. Self-disclosure is sharing personal information or feelings with others.
B is incorrect because it is an example of jealousy, not altruism. Jealousy is feeling threatened or resentful by someone else's success or happiness.
C is correct because it is an example of altruism, which is helping others without expecting anything in return. Altruism can enhance self-esteem and coping skills for clients who have breast cancer.
D is incorrect because it is an example of trust, not altruism. Trust is believing that someone is reliable and honest.
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