Author Question: A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse ... (Read 77 times)

imowrer · **on:** Jun 25, 2018

A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.)

a. Assess all mucous membranes every 4 to 8 hours.
b. Do not allow the client to eat meat or poultry.
c. Listen to lung sounds and monitor for cough.
d. Monitor the venous access device appearance with vital signs.
e. Take and record vital signs every 4 to 8 hours.

Question 2

A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate?

(Select all that apply.)
a.
Ask the family to describe their concerns more fully.
b.
Consult with a social worker, chaplain, or ethics committee.
c.
Explain the client's right to know and ask for their assistance.
d.
Have the unit manager take over the care of this client and family.
e.
Tell the family that this secret will not be kept from the client.

cloud · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A, C, D, E
Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.

Answer to Question 2

ANS: A, B, C
The client's right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the client's right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.