A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Limit the number of health care workers entering the room.

Insert an indwelling catheter to monitor for sediment in the urine.

Take the client’s temperature once per shift

Provide the client with fresh fruit to avoid constipation

Answer and Explanation

The Correct Answer is A

A.   Limiting the number of health care workers entering the room helps reduce the risk of exposure to infections.
B.   Inserting an indwelling catheter is not a routine intervention for immunosuppressed clients and may increase the risk of infection.
C.   Monitoring temperature more frequently than once per shift is crucial to detect early signs of infection in immunosuppressed clients.
D.   Fresh fruit may carry a risk of bacterial contamination, and caution should be exercised in providing it to immunosuppressed clients.

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Correct Answer is D

Explanation

A. Cryosurgery involves freezing the lesion and is typically used for benign lesions.
Malignant melanoma often requires more extensive treatment.
B. Radiation therapy may be used in certain cases, but surgical excision is often the primary treatment for malignant melanoma.
C. Chemotherapy is not the primary treatment for localized malignant melanoma but may be used for advanced cases or metastatic disease.
D. Surgical excision is the primary treatment for localized malignant melanoma, aiming to remove the tumor along with a margin of normal tissue.

A. Instruct the client on use of call light. B. Apply an ambulation alarm to the client’s leg. C. Apply restraints to the client PRN. D. Raise the four side rails of the client’s bed. E. Check on the client hourly

Correct Answer is ["A","B","D","E"]

Explanation

A. Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B. Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.

C. Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D. Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.

E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.

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A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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