Nokea
The nurse should remind the unlicensed personnel that which of the following is the most important goal in the care of the neutropenic client in isolation?
- A. Listening to the client's feelings of concern.
- B. Completing the client's care in a nonhurried manner.
- C. Performing all of the client's care at one time.
- D. Instructing the client to dispose of tissue after blowing the nose.
Correct Answer: C
Rationale: Performing all care at one time minimizes disruptions and reduces the risk of introducing pathogens to a neutropenic client in isolation. Emotional support, nonhurried care, and tissue disposal are important but secondary to infection prevention.
You may also like to solve these questions
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate?
- A. Maintaining an upright position.
- B. Restricting the diet to liquids until swallowing improves.
- C. Introducing foods on the unaffected side of the mouth.
- D. Keeping distractions to a minimum.
Correct Answer: B
Rationale: Restricting the diet to liquids increases aspiration risk, as liquids are harder to control. Upright positioning, using the unaffected side, and minimizing distractions reduce aspiration risk.
Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of:
- A. A manual toothbrush.
- B. An electric toothbrush.
- C. An irrigation device.
- D. Dental floss.
Correct Answer: D
Rationale: Dental floss removes plaque and debris, reducing the risk of oral infections that could lead to endocarditis in mitral stenosis.
While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action?
- A. Lower the head of the bed and call the physician.
- B. Prepare an aspiration tray.
- C. Mark the area with a skin pencil at the outer perippliess to the crackling.
- D. Turn off the suction of the chest drainage system.
Correct Answer: C
Rationale: The crackling sensation indicates subcutaneous emphysema. Marking the area monitors its spread, guiding further action. Lowering the bed, preparing aspiration, or turning off suction are not immediate priorities.
A 56-year-old client who recently had a right pneumonectomy for lung cancer is admitted to the oncology unit with dyspnea and fever. The nurse should:
- A. Place the client on the left side.
- B. Position the client for postural drainage.
- C. Provide education on deep breathing exercises.
- D. Instruct the client to maintain bed rest with bathroom privileges.
Correct Answer: C
Rationale: Deep breathing exercises promote lung expansion and oxygenation, which are critical for a post-pneumonectomy client with dyspnea and fever, potentially indicating infection or compromised lung function.
The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage:
- A. Blocks pain impulses from the spinal cord to the brain.
- B. Blocks pain impulses from the brain to the spinal cord.
- C. Stimulates the release of endorphins.
- D. Distracts the client's focus on the source of the pain.
Correct Answer: C
Rationale: Massage, like a back rub, stimulates endorphin release, which naturally reduces pain perception. It does not block pain impulses directly or act solely as a distraction.