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. 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.
Correct Answer is A
Explanation
Rationale:
A. This response validates the client's feelings and opens the door for further conversation without judgment, encouraging the client to express more of their thoughts.
B. While this statement acknowledges the client's feelings, it may seem dismissive or minimize the depth of the client's distress.
C. Telling the client that many people experience similar feelings can invalidate the uniqueness of their grief and may discourage them from sharing more.
D. Asking "Why" may sound accusatory and could make the client feel defensive or misunderstood.