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 C
Explanation
A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP.
B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.
C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.
D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.
Correct Answer is D
Explanation
A. Evaluate the changes the partner requests: This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
B. Review the client's plan of care: This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
C. Analyze other reports of poor care to look for trends: This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
D. Ask the partner to list specific concerns: This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.
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