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 D
Explanation
A. A client who has heart failure and received furosemide IV 8 hr ago:
Clients with heart failure require ongoing monitoring for fluid balance, electrolyte levels, and signs of worsening symptoms. IV furosemide indicates active treatment, so this client is not stable for discharge.
B. A client who was admitted 24 hr ago with chest pain:
A client with recent chest pain requires further evaluation for acute coronary syndrome (ACS). Even if pain has resolved, monitoring for cardiac events is essential. This client is not stable for discharge.
C. A client who had a seizure 48 hr ago and is on seizure precautions:
Recent seizures require continued monitoring to assess for recurrence, medication adjustments, and safety precautions. This client is not stable for discharge.
D. A client who is scheduled to have a colonoscopy in 12 hr:
A colonoscopy is an elective procedure and does not require hospitalization. This client is stable and can be discharged to free up resources for mass casualty victims.
Correct Answer is C
Explanation
A. Bradycardia is not expected with dehydration. Instead, tachycardia occurs as a compensatory response to low blood volume.
B. Edema is not a symptom of dehydration. Instead, dehydration leads to decreased tissue perfusion and dry mucous membranes.
C. Hypotension occurs due to decreased blood volume from fluid loss, leading to low blood pressure and potential dizziness or weakness.
D. Crackles are not expected in dehydration. Instead, lung sounds are typically clear unless another condition is present.
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