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 {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Choice A rationale:
The client's low platelet count (90 x 10⁹/L) is a significant risk factor for developing Disseminated Intravascular Coagulation (DIC), a condition characterized by abnormal blood clotting and bleeding. The client's history of cancer and symptoms such as unexplained bruising and fatigue further support this risk.
Choice B rationale:
Hyperkalemia is characterized by high potassium levels, but the client's potassium level is within the normal range (4.1 mmol/L), so this is not a risk factor.
Choice C rationale:
Hyponatremia is a condition of low sodium levels in the blood. The client's sodium level is normal (137 mmol/L), so this is not a risk factor.
Choice D rationale:
Pneumonia is a lung infection, and the client's oxygen saturation is normal (98% on room air), indicating no immediate risk of pneumonia.
Choice E rationale:
Acute nephritic syndrome is a kidney disorder that can cause elevated blood urea nitrogen (BUN) and creatinine levels. The client's BUN is slightly elevated (22 mg/dL), but her creatinine level is normal (1.0 mg/dL), making this less likely.
Correct Answer is D
Explanation
Choice A rationale
Liver cancer is not associated with elevated prostate specific antigen (PSA) levels. PSA is a protein produced primarily by prostate cells, and its elevation is typically linked to prostate-related conditions rather than liver disorders.
Choice B rationale
Breast cancer is not associated with elevated PSA levels. PSA is specific to prostate cells, which are not present in breast tissue. Therefore, PSA is not a marker used in diagnosing or monitoring breast cancer.
Choice C rationale
Colon cancer is not linked to elevated PSA levels. PSA is not a biomarker for colon cancer, as it is specific to the prostate gland. Other markers, such as carcinoembryonic antigen (CEA), are more relevant for colon cancer.
Choice D rationale
Prostatic cancer is associated with elevated PSA levels. PSA is produced by prostate cells, and elevated levels can indicate prostate cancer, benign prostatic hyperplasia (BPH), or inflammation of the prostate.
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