A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Ensure sterilization of nondisposable items with ethylene oxide.

Wrap monitoring cords with stockinette and tape them in place.

Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.

Wear hypoallergenic latex gloves that contain powder.

Answer and Explanation

The Correct Answer is B

A. Ensure sterilization of nondisposable items with ethylene oxide: Ethylene oxide is a sterilizing agent used for heat-sensitive equipment, but it does not remove latex proteins from items that contain latex. If equipment contains latex, sterilization alone will not eliminate the allergenic proteins capable of triggering a reaction.

B. Wrap monitoring cords with stockinette and tape them in place: Clients with latex allergy must be protected from direct contact with items that may contain latex components. Covering monitoring cords with stockinette or similar barriers prevents skin contact with potential latex-containing materials in the operating environment. This reduces the risk of contact reactions.

C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication: Disinfecting an injection port with chlorhexidine removes microorganisms but does not neutralize latex proteins. For clients with latex allergy, latex-free IV equipment should be used rather than attempting to disinfect latex components.

D. Wear hypoallergenic latex gloves that contain powder: Hypoallergenic latex gloves still contain latex proteins that can trigger allergic reactions. Powdered gloves further increase the risk because the powder can carry airborne latex particles that are easily inhaled or deposited on surfaces. In a latex-allergic environment, non-latex gloves such as nitrile or vinyl are required.

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Correct Answer is D

Explanation

A. "I am ready to learn about chemotherapy to help cure my cancer.": This statement indicates that the client is focused on curative treatment rather than comfort-oriented care. Introducing palliative care at this stage may not align with the client’s current goals and could cause confusion or distress, as palliative care emphasizes quality of life rather than curing the disease.

B. "I just want you to give me something to get this over with soon.": This statement may reflect fear, despair, or a desire to hasten death. While it signals emotional distress, it does not indicate readiness to discuss palliative care. The nurse would first need to assess for psychological support, clarify the client’s wishes, and ensure safety before initiating a palliative care conversation.

C. "I know that many people have recovered fully from cancer, and so will I.": The client demonstrates a strong focus on recovery and hope for a cure. This indicates that they are not yet receptive to discussions about end-of-life care or palliative interventions, as their attention is directed toward disease eradication rather than symptom management.

D. "I want you to tell me about measures available to keep me comfortable.": This statement directly reflects the client’s interest in comfort, symptom relief, and quality of life. It demonstrates readiness to receive information about palliative care interventions, such as pain management, emotional support, and end-of-life planning, making it the most appropriate cue for the nurse to proceed with palliative care education.

A. "You should have an eye examination every 2 years." B. "You should receive a tetanus booster every 5 years." C. "You should receive a shingles vaccine when you are 70 years old." D. "You should receive a pneumococcal vaccine when you are 50 years old."

Correct Answer is A

Explanation

A. "You should have an eye examination every 2 years.": Regular eye exams are recommended for older adults to detect age-related visual changes, such as cataracts, glaucoma, and macular degeneration. A comprehensive eye exam every 1–2 years helps maintain vision, detect disease early, and prevent complications like falls or loss of independence. This is consistent with guidelines from the American Academy of Ophthalmology and the CDC.

B. "You should receive a tetanus booster every 5 years.": For older adults, tetanus boosters are recommended every 10 years, not every 5 years. Administering it more frequently than indicated does not provide additional protection and is unnecessary. Correct timing ensures optimal immunity while avoiding over-vaccination.

C. "You should receive a shingles vaccine when you are 70 years old.": The shingles (herpes zoster) vaccine is recommended for adults aged 50 and older, not at a specific age like 70. Receiving it earlier provides protection against shingles and its complications, such as postherpetic neuralgia. Waiting until age 70 may delay critical preventive care.

D. "You should receive a pneumococcal vaccine when you are 50 years old.": Pneumococcal vaccination recommendations depend on individual risk factors. Routine vaccination is generally advised for all adults aged 65 and older, with earlier vaccination for those with chronic illnesses or immunocompromised status. Recommending it at age 50 for all older adults is not consistent with standard guidelines.

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A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

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