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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "How are things going at your job?" This response redirects the conversation rather than addressing the client's emotional state.
B. "Why do you think this is happening to you?" This question may come across as challenging or blaming, which is not therapeutic.
C. "You must be feeling very frightened right now." This response validates the client's emotions, showing empathy and encouraging further expression of feelings.
D. "Maybe you should think more positively." This dismisses the client's distress and does not provide therapeutic support.
Correct Answer is []
Explanation
Potential Condition: Opioid intoxication
Actions to Take:
- Obtain a prescription for naloxone
- Prepare to initiate mechanical ventilation
Parameters to Monitor:
- Pupillary reaction,
- Respiratory rate
Rationale:
- Potential Condition: The client presents with shallow breathing, slurred speech, confusion, pupillary constriction, and bradycardia, which are classic signs of opioid intoxication. The history of back pain also suggests possible opioid use.
- Actions to Take:
- Naloxone is an opioid antagonist that can rapidly reverse respiratory depression caused by opioid overdose.
- Mechanical ventilation may be necessary if respiratory depression is severe and does not improve with naloxone administration.
- Parameters to Monitor:
- Pupillary reaction is important because opioids cause pupillary constriction (miosis). Improvement in pupillary size and reaction indicates the opioid effects are wearing off.
- Respiratory rate should be closely monitored since opioid overdose primarily affects respiratory drive, leading to hypoxia and potential respiratory failure.
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