A client is receiving chemotherapy and is at risk for neutropenia. Which precaution should the nurse implement?

Correct Answer: C

Rationale: The correct answer is C: Place the client in a private room. This is important to reduce the risk of infection for the client with neutropenia, as being in a private room minimizes exposure to pathogens from other individuals. Neutropenia is a condition where there is a low level of neutrophils, a type of white blood cell that helps fight infections. By placing the client in a private room, the nurse can control the environment and limit the client's exposure to potential sources of infection. Choice A is incorrect because regular visitors may introduce pathogens that could increase the client's risk of infection. Choice B is incorrect as live vaccines are contraindicated in clients receiving chemotherapy due to their weakened immune system. Choice D is incorrect because while fresh fruits and vegetables are important for overall health, in this case, the risk of infection outweighs the benefits of a diet high in these foods.

Correct Answer: B

Rationale: The correct answer is B: Inspire deeply and slowly over 3 to 5 seconds. This technique is recommended for using an incentive spirometer (IS) to maintain sustained maximal inspiration. Slow, deep inhalation helps fully expand the lungs and improve lung function postoperatively. A: Exhaling forcefully into the tubing is incorrect because the purpose of using an IS is to promote deep inhalation, not forceful exhalation. C: Breathing into the spirometer using normal breath volumes is incorrect as it does not promote maximal inspiration and may not fully expand the lungs. D: Performing IS breathing exercises every 6 hours is incorrect as regular, consistent practice throughout the day is recommended for optimal lung recovery.

Correct Answer: C

Rationale: The correct answer is C: Presbycusis. This age-related condition refers to gradual hearing loss typically seen in older adults. In this case, the client's complaint of people whispering and mumbling suggests difficulty hearing clearly, which aligns with symptoms of presbycusis. Delirium (choice A) is characterized by acute confusion and disorientation, not specifically related to hearing loss. Presbyopia (choice B) is a condition of aging that affects near vision, not hearing. Cerebral dysfunction (choice D) refers to broader cognitive impairment, not specifically related to hearing loss as in presbycusis. Therefore, choice C is the most likely age-related condition in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Kayexalate retention enema. In acute renal failure with high serum potassium levels, the priority is to lower potassium levels to prevent cardiac complications. Kayexalate works by exchanging sodium ions for potassium ions in the intestines, promoting potassium excretion in the feces. This intervention helps reduce serum potassium levels quickly. A: Nitrofurantoin is an antibiotic used to treat urinary tract infections, unrelated to managing hyperkalemia. B: Erythropoietin is a hormone used to stimulate red blood cell production, not indicated for reducing potassium levels. D: Azathioprine is an immunosuppressant used for various conditions like autoimmune diseases, not for managing hyperkalemia. In summary, the correct intervention is to administer a Kayexalate retention enema to lower serum potassium levels effectively in acute renal failure. Other options are not appropriate for managing hyperkalemia.

Correct Answer: D

Rationale: The correct answer is D: Risk for injury. The client's symptoms of disorientation, wandering, decreased appetite, and difficulty sleeping indicate an increased risk for falls, accidents, or getting lost. Ensuring the client's safety and preventing any potential harm is the priority. A: Disturbed thought processes may contribute to the client's disorientation but do not pose an immediate threat to their safety. B: Altered sleep pattern is concerning but is secondary to the risk of injury in this scenario. C: Imbalanced nutrition: less than is important, but the immediate priority is addressing the client's safety due to the risk of injury. In summary, the priority nursing problem for this client is the risk for injury due to their disorientation and wandering behavior, which could lead to accidents or harm.