A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Use an electric shaver.
Avoid crowds.
Take temperature weekly.
Consume a low-residue diet.
Monitor for bruising.
Correct Answer : A,B,E
Choice A Reason:
Using an electric shaver is recommended for clients who have received chemotherapy because it reduces the risk of cuts and bleeding. Chemotherapy can lower platelet counts, leading to an increased risk of bleeding. Traditional razors can cause nicks and cuts, which can be problematic for clients with low platelet counts.
Choice B Reason:
Avoiding crowds is crucial for clients who have received chemotherapy because their immune systems are often weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to pathogens, which can lead to serious infections in immunocompromised individuals.
Choice C Reason:
Taking temperature weekly is not sufficient for clients who have received chemotherapy. These clients are at a higher risk of infections, and any sign of fever should be monitored closely. It is generally recommended to take the temperature daily or more frequently if the client feels unwell.
Choice D Reason:
Consuming a low-residue diet is not typically necessary for clients who have received chemotherapy unless they are experiencing specific gastrointestinal issues. A balanced diet with adequate nutrients is usually recommended to support overall health and recovery.
Choice E Reason:
Monitoring for bruising is important for clients who have received chemotherapy because it can indicate low platelet counts or other bleeding disorders. Early detection of bruising can help in managing and preventing more serious bleeding complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
“It is okay to not want to touch the burned areas of your body.” This statement is empathetic and acknowledges the client’s feelings, but it does not provide a constructive way to address their concerns about altered appearance. While it is important to validate the client’s feelings, offering a solution or support mechanism is more beneficial.
Choice B Reason
“Cosmetic surgery should be performed within the next year to be effective.” This statement is misleading. While timely intervention can be important, the timing of reconstructive or cosmetic surgery depends on various factors, including the extent of the burns, the healing process, and the patient’s overall health. It is not accurate to generalize that surgery must be performed within a year.
Choice C Reason
“Reconstructive surgery can completely restore your previous appearance.” This statement is incorrect and can give false hope. Reconstructive surgery aims to improve function and appearance, but it cannot completely restore the previous appearance. Managing expectations is crucial in the recovery process.
Choice D Reason
“It could be helpful for you to attend a support group for people who have burn injuries.” This statement is correct. Support groups provide emotional and psychological support, helping burn survivors cope with changes in appearance and other challenges. They offer a sense of community and shared experiences, which can be very beneficial for recovery.
Correct Answer is C
Explanation
Choice A Reason
Axillary temperature 37.2° C (99° F). This temperature is within the normal range and does not indicate an immediate need for intervention. Normal body temperature ranges from 36.1° C to 37.2° C (97° F to 99° F).
Choice B Reason
Apical pulse 100/min. While a pulse rate of 100 beats per minute is on the higher end of the normal range, it is not necessarily indicative of an immediate life-threatening condition. Normal resting heart rate for adults ranges from 60 to 100 beats per minute.
Choice C Reason
Respiratory rate 30/min. This is the correct answer. A respiratory rate of 30 breaths per minute is significantly higher than the normal range of 12 to 20 breaths per minute for adults. This could indicate respiratory distress or other complications that require immediate intervention.
Choice D Reason
Blood pressure 140/84 mm Hg. While this blood pressure reading is elevated and may require monitoring, it does not indicate an immediate life-threatening condition. Normal blood pressure is typically around 120/80 mm Hg, but a reading of 140/84 mm Hg is not uncommon and can be managed with appropriate care.
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