A nurse is caring for a client with sickle cells disease. Which nursing action is most effective in reducing potential for sepsis in this client
a. check vitals every 4 hours
b. perform frequent and thorough hand washing
c. administer prophylactic drug therapy
d. monitor for abnormal laborato...
Practice Questions for 401 Exam 1 Fully
Solved.
A nurse is caring for a client with sickle cells disease. Which nursing action is most effective in reducing
potential for sepsis in this client
a. check vitals every 4 hours
b. perform frequent and thorough hand washing
c. administer prophylactic drug therapy
d. monitor for abnormal laboratory values - Answer b. Perform frequent and thorough hand washing
The most effective nursing action to reduce the risk for sepsis in a client with sickle cell anemia is to
perform frequent and thorough handwashing. Prevention and early detection strategies are used to
protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost
importance.
Taking vital signs every 4 hours will help with early detection of infection but is not prevention. Drug
therapy is a major defense against infections that develop in the client with sickle cell disease but is not
the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client
for infection and monitoring the daily complete blood count with differential white blood cell count is
early detection, not prevention.
Which nursing intervention most effectively protects a client with thrombocytopenia
a. take rectal temperatures
b. avoid use of dentures
c. encourage use of an electric shaver
d. apply warm compresses on trauma sites - Answer c. encourage use of electric razor
,The most effective nursing intervention that protects a client with thrombocytopenia is encouraging the
client to use an electric shaver. This client must be advised to use an electric shaver instead of a razor.
Any small cuts or nicks can cause problems because of the prolonged clotting time.
To prevent rectal trauma, rectal thermometers would not be used. Oral or tympanic temperatures would
be taken. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not
rub. Ice (not heat) would be applied to areas of trauma.
A client with leukemia is being discharged from the hospital. The nurse's discharge instructions say to
keep regularly scheduled follow-up primary health care provider appointments. The client says, "I don't
have transportation." Which is the most appropriate nursing response?
a. You can take the bus
b. I may be able to take you
c. the local American Cancer Society may be able to help
d. a pharmaceutical company might be able to help - Answer c. the local American cancer society may
be able to help
The most appropriate nursing response to the client who does not have transportation for follow-up
appointments is that "the local American Cancer Society may be able to help." Many local units of the
American Cancer Society offer free transportation to clients with cancer, including those with leukemia.
Telling the client to take the bus is dismissive and does not take into consideration the client's situation
(e.g., the client may live nowhere near a bus route). Although the nurse offering to take the client is
compassionate, it is not appropriate for the nurse to offer the client transportation. Suggesting a
pharmaceutical company is not the best answer. Drug companies typically do not provide this type of
service.
Which client statement indicates in-home stem cell transplantation is not a viable option?
a. I was a nurse, so I can take care of myself
b. I don't feel strong enough, but my wife said she would help
c. We live 5 miles from the hospital
d. I will have lots of medicine to take - Answer a. I was a nurse so I can take care of myself
,The client statement that indicates that in-home stem cell transplantation is not a viable option is "I was
a nurse, so I can take care of myself." Stem cell transplantation in the home setting requires support,
assistance, and coordination from others. The client cannot manage this type of care on his own.
It is acceptable for the client's spouse to support the client undergoing this procedure. It is not
unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance from the
hospital, in case of emergency.
The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client
identification?
a. Check the client's armband
b. Review all information with another registered nurse (RN)
c. Ask the client's name
d. Verify the client's room number - Answer b. review all information with another registered nurse
(RN)
With another registered nurse, all information must be reviewed. This process includes verifying the
client by name and number, checking blood compatibility, and noting the expiration time. Human error is
the most common cause of ABO incompatibility reactions, even for experienced nurses.
Asking the client's name and checking the client's armband are not adequate for identifying the client
before transfusion therapy. Using the room number to verify client identification is never appropriate.
What is the most important environmental risk for developing leukemia?
a. Living near high-voltage power lines
b. Direct contact with others with leukemia
c. Smoking cigarettes
d. Family history - Answer c. Smoking cigarettes
The most important environmental risk for developing leukemia is smoking cigarettes. According to the
American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is cigarette
smoking.
, Genetics is a strong indicator, but it is not an environmental risk factor. According to the ACS, living near
high-voltage power lines is not a proven risk factor for leukemia. Leukemia is not contagious.
A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which
potential problem takes priority in the client's nursing care plan?
a. Fluid overload (overhydration)
b. Hemorrhage
c. Infection
d. Hypoxia - Answer c. infection
Avoiding infection is the priority potential problem when caring for a newly diagnosed client with
leukemia.
Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.
The nurse is assessing the endurance level of a client in a long-term care facility. What question does the
nurse ask to get this information?
a. "Are your feet or hands cold, even when you are in bed?"
b. "How much exercise do you get?"
c. "Do you feel more tired after you get up and go to the bathroom?"
d. "What is your endurance level?" - Answer c. do you feel more tired after you get up and go to the
bathroom
Asking about feeling tired after using the bathroom is the best question to ask to assess a client's
endurance level. This question is pertinent to the client's activity and provides a comparison. The specific
activity helps the client relate to the question and provides needed answers.
The hospitalized client typically does not get much exercise. This would be a difficult assessment for a
client in long-term care facility to make. Asking the client about his or her endurance level is too vague.
The client may not know how to answer this question. Asking about cold feet or hands does not address
the client's endurance.
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