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A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take to prevent infection?
- A. Encourage the client to avoid fresh fruits and vegetables.
- B. Administer prophylactic antibiotics daily.
- C. Monitor the client's white blood cell count regularly.
- D. Instruct the client to avoid crowded places.
Correct Answer: C
Rationale: Monitoring WBC counts detects neutropenia early, guiding infection prevention. Fresh produce is safe if washed, antibiotics aren't routine, and avoiding crowds is secondary.
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A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz. of which of the following beverages contains the least amount of caffeine?
- A. Hot cocoa
- B. Cola soft drink
- C. Instant coffee
- D. Brewed green tea
Correct Answer: A
Rationale: Hot cocoa contains approximately 5 mg of caffeine per 240 mL, significantly less than cola soft drink (24-31 mg), instant coffee (57-96 mg), or brewed green tea (20-45 mg). Choosing hot cocoa helps reduce caffeine intake effectively.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.1°C (100.5°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.1°C suggests possible infection, requiring reporting. Pain, no bowel movement, or minimal drainage are expected post-appendectomy.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Remind the client of the day and time often.
- B. Offer the client several choices at mealtimes.
- C. Avoid discussing the client's fears.
- D. Alternate daily caregivers.
Correct Answer: A
Rationale: Frequent orientation to time and place reduces confusion in delirium. Multiple choices can overwhelm, discussing fears supports emotional needs, and consistent caregivers minimize disorientation.
A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports shoulder pain.
- B. The client's temperature is 38.2°C (100.8°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with slight redness.
Correct Answer: B
Rationale: A temperature of 38.2°C suggests infection, requiring reporting. Shoulder pain is referred pain, no bowel movement is expected, and slight redness is normal.
A nurse is reinforcing teaching with a client who has a new prescription for doxycycline. Which of the following instructions should the nurse include?
- A. Take this medication with an antacid.
- B. You might need to wear sunscreen while taking this medication.
- C. You need to refrigerate this medication.
- D. You should stop taking this medication if you feel better.
Correct Answer: B
Rationale: Doxycycline increases photosensitivity, requiring sunscreen. Antacids reduce absorption, refrigeration isn't needed, and stopping early risks resistance.