The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for:

Correct Answer: D

Rationale: When a client is receiving antibiotics to treat an infection, especially a gram-negative bacterial infection, the antibiotics may disrupt the balance of normal flora in the gastrointestinal tract. This disruption can lead to an overgrowth of pathogenic bacteria, resulting in diarrhea. Clostridium difficile-associated diarrhea is a common complication of antibiotic therapy due to the disruption of normal gut flora. Therefore, the nurse must monitor the client for signs and symptoms of diarrhea and intervene promptly to prevent complications such as dehydration and electrolyte imbalances. Platelet dysfunction, stomatitis, and oliguria/dysuria are not typically associated with the destruction of normal flora due to antibiotic therapy for a gram-negative bacterial infection.

Correct Answer: B

Rationale: The correct action for the nurse to teach a client with pancytopenia caused by chemotherapy is to avoid traumatic injuries and exposure to any infection. Pancytopenia is a condition characterized by low levels of all blood cell types - red blood cells, white blood cells, and platelets. This leaves the individual vulnerable to infections, easy bruising, and bleeding. By advising the client to avoid traumatic injuries and exposure to infection, the nurse is helping to reduce the risk of further complications that can arise from low blood cell counts. This includes advising the client on taking precautions such as gentle handling to prevent skin injury, using a soft toothbrush for oral care, and avoiding contact with individuals who are sick to minimize the risk of infection.

Correct Answer: B

Rationale: Pallor, or paleness of the skin, is an early sign of anemia. Anemia occurs when there is a decrease in the number of red blood cells or the amount of hemoglobin in the blood, resulting in reduced oxygen supply to the body's tissues. This lack of oxygen can cause the skin to appear pale due to decreased blood flow. Other common symptoms of anemia may include fatigue, weakness, shortness of breath, dizziness, and cold hands and feet. Palpitations, glossitis, and weight loss are not typically early signs of anemia.

Correct Answer: C

Rationale: The primary nursing intervention in the administration of blood is to correctly identify the client. This is crucial to ensure that the right blood is being administered to the right patient to prevent transfusion reactions and ensure patient safety. Before any blood transfusion, the nurse must verify the patient's identity using at least two unique identifiers, such as name, date of birth, and hospital or medical record number. Patient safety hinges on this critical step, making it the priority when administering blood products. While monitoring vital signs, checking the flow rate, and maintaining blood temperature are all important aspects of blood transfusion management, identifying the client is fundamental and must come first to prevent errors.

Correct Answer: A

Rationale: Heparin is a medication commonly used to prevent clot formation in various clinical conditions, including Disseminated Intravascular Coagulation (DIC). DIC is a serious condition characterized by abnormal blood clotting and bleeding throughout the body. Heparin works by inhibiting the formation of new clots and preventing the existing clots from further growing, thus helping to manage and prevent complications associated with DIC. By using heparin, the aim is to help stabilize the patient's clotting process and reduce the risk of severe complications such as organ damage or failure.