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 B
Explanation
Rationale:
A. Similar to the previous question, a quick inhalation is not recommended; the child should take a slow, deep breath for effective medication delivery.
B. Taking the medication 5 minutes before playing sports is ideal as it allows the medication to work quickly, ensuring better performance and control of asthma symptoms during activity.
C. Cleaning the mouthpiece with warm water every 2 weeks is insufficient; it should be cleaned more frequently, typically after each use, to maintain hygiene.
D. Waiting 10 seconds between inhalations is appropriate, but the focus on the timing before sports is critical for proper management of asthma symptoms.
Correct Answer is ["A","C","D","E"]
Explanation
Rationale:
A. Administering methylergonovine maleate is indicated if the uterus is boggy (atonic), as it helps to contract the uterus and reduce the risk of postpartum hemorrhage.
B. Massaging a firm fundus is not appropriate; instead, the nurse should massage a boggy (soft) fundus to promote uterine contraction.
C. Documenting fundal height is a necessary action to assess uterine involution and ensure it is progressing as expected after delivery.
D. Observing the lochia during palpation of the fundus is important to assess for any abnormal findings, such as heavy bleeding, which could indicate complications.
E. Determining whether the fundus is midline is crucial; a displaced fundus may indicate bladder distention, which can affect uterine contraction.