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
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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Related Questions
Correct Answer is A
Explanation
A. Influenza vaccines are typically produced using eggs, and individuals with egg allergies may react to the vaccine. However, there are egg-free alternatives available, and consultation with an allergist is recommended in such cases.
B. Polio vaccines do not contain egg proteins and are safe for individuals with egg allergies.=
C. Hib vaccines are not contraindicated for individuals with egg allergies.
D. Hepatitis B vaccines do not contain egg proteins and are generally safe for individuals with egg allergies.
Correct Answer is D
Explanation
A. While discomfort can occur, it is not an expected or acceptable part of end-of-life care. Effective pain management is a key priority, and discomfort should be addressed promptly to ensure the client’s comfort and dignity.
B. While true, this statement does not directly address the expectation of discomfort at the end of life.
C. While pain can be present in older adults, the statement does not specifically address the end-of-life context.
D.Fear of addiction is a common concern among clients and families, even at the end of life. Nurses should educate clients and families about the importance of managing pain effectively and emphasize that addiction is not a concern when opioids are used appropriately for end-of-life care. This helps alleviate anxiety and encourages adherence to prescribed pain management regimens.
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