Nokea
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Visitors from outside the hospital
- C. Foods high in vitamin C
- D. A humidifier in the room
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and potted plants can harbor bacteria and fungi, increasing the risk of infection. Restricting these items helps minimize exposure to pathogens. Choices B and D are incorrect as long as visitors are screened for infections and the humidifier is cleaned regularly. Choice C, foods high in vitamin C, is incorrect as these foods can actually help boost the immune system.
You may also like to solve these questions
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?
- A. A slice of cheese
- B. A small handful of almonds
- C. A baked apple
- D. Carrot sticks with hummus
Correct Answer: A
Rationale: The correct answer is A: A slice of cheese. Cheese is high in fat, sodium, and cholesterol, making it unsuitable for a low-fat, low-sodium, and low-cholesterol diet. The client needs further teaching to understand that cheese does not align with their dietary restrictions. The other options (B, C, D) are suitable choices for a low-fat, low-sodium, and low-cholesterol diet. Almonds are a source of healthy fats, a baked apple is low in fat and sodium, and carrot sticks with hummus are low in fat and cholesterol while providing fiber and nutrients. These options align with the client's dietary needs and do not require further teaching.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has a wound infection and is on antibiotics.
- B. The client who has gastroenteritis and is febrile.
- C. The client who is receiving IV fluids and is in pain.
- D. The client who is on a clear liquid diet and has hypokalemia.
Correct Answer: B
Rationale: The correct answer is B. The client with gastroenteritis and fever is at risk for fluid volume deficit due to increased fluid loss from vomiting and diarrhea. Fever also increases fluid loss through perspiration. The other choices do not directly indicate increased fluid loss. A: Antibiotics for wound infection may not directly lead to fluid volume deficit. C: IV fluids would help maintain hydration status, so this client is not at risk for deficit. D: Hypokalemia may be related to electrolyte imbalance, but not necessarily fluid volume deficit.
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
- A. Give the ordered KCL as prescribed.
- B. Hold the KCL and notify the healthcare provider.
- C. Administer potassium via IV push.
- D. Check the client's potassium level again in 1 hour.
Correct Answer: A
Rationale: The correct answer is A: Give the ordered KCL as prescribed. The nurse should administer potassium chloride as prescribed because the client's potassium level of 3.2 mEq/L is within the normal range (3.5-5.0 mEq/L). Potassium chloride is indicated for clients with hypokalemia (low potassium levels), and the client's level falls within the normal range, so administering the ordered KCL is appropriate. Holding the KCL is unnecessary since the potassium level is not critically low. Administering potassium via IV push is not indicated as the client's potassium level is not critically low. Checking the client's potassium level again in 1 hour is unnecessary as the level is already within the normal range.
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
- A. DIC is caused by abnormal coagulation involving fibrinogen.
- B. DIC is caused by increased fibrinogen levels.
- C. DIC is caused by a reduction in platelet production.
- D. DIC is caused by a decrease in clotting factors.
Correct Answer: A
Rationale: The correct answer is A because DIC is characterized by abnormal coagulation involving fibrinogen. In septic shock, the body's response triggers widespread activation of the coagulation system, leading to the consumption of clotting factors like fibrinogen. This results in the formation of microclots throughout the body, leading to organ dysfunction. Choices B, C, and D are incorrect as DIC is not caused by increased fibrinogen levels, a reduction in platelet production, or a decrease in clotting factors. It is essential for the nurse to emphasize the role of abnormal coagulation involving fibrinogen in DIC to help the client understand the pathology and potential complications associated with septic shock.
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
- A. Keep the knee elevated above the heart at all times.
- B. Avoid physical therapy for 2 weeks.
- C. Apply ice to the affected area.
- D. Limit fluid intake to reduce swelling.
Correct Answer: C
Rationale: The correct answer is C: Apply ice to the affected area. Ice application helps reduce swelling and pain post-surgery. Keeping the knee elevated above the heart (A) is important, but not at all times as it can lead to other issues like blood pooling. Avoiding physical therapy for 2 weeks (B) is incorrect as early mobilization is crucial for recovery. Limiting fluid intake (D) is not recommended as hydration is essential for healing.