A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse
include?
Use clean technique for invasive procedures.
Allow healthy children to visit.
Make sure the client's room is cleaned every 2 days.
Monitor the client's temperature every 4 hr.
The Correct Answer is D
A. Use clean technique for invasive procedures is incorrect because clients with neutropenia require sterile technique for invasive procedures to minimize infection risk.
B. Allow healthy children to visit is incorrect because children can be asymptomatic carriers of infections, which can be life-threatening for immunocompromised clients.
C. Make sure the client's room is cleaned every 2 days is incorrect because a neutropenic client’s room should be cleaned daily to reduce exposure to pathogens.
D. Monitor the client's temperature every 4 hr is correct because even a slight fever can indicate infection, which can be life-threatening for a client with neutropenia. Frequent monitoring allows for early detection and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
Correct Answer is A
Explanation
A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.
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