A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?
Restrict visits from young children to 2 hr per day.
Avoid including raw fruits in the client's diet.
Measure the client's temperature every 8 hr.
Use disposable gloves from a box outside the client's room.
The Correct Answer is B
Rationale:
A. While restricting visits from young children may help reduce infection risk, it is not a sufficient or specific intervention for neutropenic precautions.
B. Avoiding raw fruits is critical because they can harbor bacteria and increase the risk of infection in neutropenic clients. Cooked fruits are safer options.
C. Measuring temperature should occur more frequently than every 8 hours, ideally every 4 hours or more, to quickly identify fever, a sign of infection.
D. Disposable gloves should be used from within the client's room to maintain strict infection control measures; using gloves from outside could introduce contaminants.
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Correct Answer is C
Explanation
Rationale:
A. Diarrhea is not a typical manifestation of ovarian cancer and may be more related to gastrointestinal issues.
B. Urinary retention can occur but is not a common initial symptom associated with ovarian cancer.
C. Abdominal bloating is a common symptom associated with ovarian cancer and should be included in the educational session. It may occur due to fluid accumulation or tumor growth.
D. Purulent discharge is not a typical manifestation of ovarian cancer and may suggest an infection rather than a cancer diagnosis.
Correct Answer is C
Explanation
Rationale:
A. Reporting suspected child maltreatment is a legal and ethical responsibility of the nurse; this action is appropriate and does not require intervention.
B. Notifying the health department about a client's diagnosis of chlamydia is a legal requirement, as it is a reportable disease, so this action is appropriate.
C. Sharing a client’s diagnosis with a hospital chaplain without the client's consent could violate the client's confidentiality and requires intervention.
D. Informing the provider about a client's suicide plan is a critical action for patient safety and does not require intervention.