A nurse is planning care for a client who is to undergo a stem cell transplant.
Which of the following actions should the nurse plan to take?
Provide the client with 1,000 mL of water to drink every 12 hr.
Keep blood pressure equipment in the client's room.
Place the client in a negative airflow room.
Monitor the client's vital signs once every 8 hr.
The Correct Answer is B
Choice A rationale
Providing 1,000 mL of water every 12 hours is not directly related to preventing infection or other complications post-transplant.
Choice B rationale
Keeping blood pressure equipment in the client's room helps prevent cross-contamination and infection by not sharing equipment with other clients.
Choice C rationale
A negative airflow room is used for clients with airborne infections, not for those undergoing a stem cell transplant.
Choice D rationale
Monitoring vital signs every 8 hours is insufficient; more frequent monitoring is needed post-transplant to detect complications early.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging the client to drink cool water or sports drinks is appropriate for mild dehydration or heat exhaustion but not sufficient for severe heat-related illness like heat stroke, where immediate medical intervention is needed.
Choice B rationale
Administering acetaminophen 650 mg orally can help reduce fever, but it does not address the underlying issue of hyperthermia and will not provide immediate cooling needed in this emergency.
Choice C rationale
Starting an intravenous line and infusing 0.9% saline solution helps rapidly replace fluids lost through sweating and can stabilize the client's condition by rehydrating and cooling them effectively.
Choice D rationale
Encouraging rest and reassessing in 15 minutes would delay necessary medical treatment in a situation where immediate action is critical due to the severity of the client's symptoms.
Correct Answer is C
Explanation
Choice A rationale
The client's complete blood count does not specifically indicate an increased risk for bleeding. Platelet levels would need to be evaluated for bleeding risk.
Choice B rationale
Erythropoiesis stimulating agents are used for anemia but are not indicated based on the provided CBC.
Choice C rationale
The client is at increased risk of infection due to low white blood cell count (leukopenia), which indicates immunosuppression.
Choice D rationale
While a high-protein diet is beneficial during cancer treatment, the CBC results highlight an infection risk as the primary concern.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.