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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Anticipated Interventions:

Initiate an IV infusion of lactated Ringer's
Place the client in a left lateral position
Maintain continuous monitoring of the FHR

Contraindicated Intervention:

Monitor blood pressure every hour

Rationale:

Initiate an IV infusion of lactated Ringer’s: Hydration is important for labor progression and maternal hemodynamic stability, especially considering the client has a history of chronic hypertension and gestational diabetes.
Place the client in a left lateral position: This improves uteroplacental perfusion, helping to optimize fetal oxygenation.
Maintain continuous monitoring of the FHR: The presence of meconium-stained amniotic fluid and an elevated FHR (165/min) suggests potential fetal distress, warranting continuous fetal monitoring.
Monitor blood pressure every hour (Contraindicated): The client has chronic hypertension and gestational diabetes, both of which increase the risk for complications like preeclampsia and fetal distress. More frequent BP monitoring (e.g., every 15-30 minutes) is necessary to detect any abnormalities early.

A. Administer a stimulant to the client. B. Administer a diuretic to the client. C. Measure the client's urine specific gravity. D. Insert an NG tube for the client.

Correct Answer is C

Explanation

A. Stimulants should not be administered to clients with acute alcohol toxicity, as they can increase agitation and cardiovascular stress.
B. Diuretics are not used for alcohol toxicity because they do not effectively eliminate alcohol and may contribute to dehydration.
C. Measuring urine specific gravity helps assess hydration status and kidney function, which can be affected by acute alcohol toxicity.
D. An NG tube is not routinely indicated unless the client is at risk for aspiration or requires gastric lavage due to severe intoxication.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an antepartum unit is caring for a client. Exhibits For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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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?