Nokea
A client with leukemia is admitted with a white blood cell count of 2,000/mm³ and a fever of 101.8°F (38.8°C). The nurse should initiate:
- A. Contact precautions.
- B. Reverse isolation.
- C. Standard precautions.
- D. Droplet precautions.
Correct Answer: B
Rationale: A low white blood cell count (2,000/mm³) with fever indicates neutropenia and high infection risk, necessitating reverse isolation to protect the client from pathogens.
You may also like to solve these questions
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife's impending death from aggressive breast cancer. The nurse should:
- A. Refer the family to pastoral care services.
- B. Encourage the husband to come to terms with his own grief first.
- C. Suggest that the children be told nothing until after death occurs.
- D. Begin education about strategies for communication with his children.
Correct Answer: D
Rationale: Educating the husband on communication strategies helps him prepare his children for their mother's death, fostering understanding and emotional support.
Which intervention is appropriate for a client on hemodialysis?
- A. Check fistula for a thrill.
- B. Restrict all fluids.
- C. Administer heparin post-dialysis.
- D. Encourage high-protein diet.
Correct Answer: A
Rationale: Checking for a thrill ensures fistula patency for dialysis.
A client with terminal cancer wishes to die at home. The nurse should:
- A. Arrange for home hospice services.
- B. Encourage hospitalization for better care.
- C. Advise against it due to lack of equipment.
- D. Inform the client it's not possible.
Correct Answer: A
Rationale: Arranging home hospice services supports the client's wish to die at home, providing necessary care and support in a comfortable environment.