A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer.
For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.
Place the client on droplet precautions.
Insert an indwelling urinary catheter.
Place the client in a private room
Check the client's rectal temperature once daily.
Rinse the client's mouth with 0.9% sodium chloride every 4 hours
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}
Placing the client on droplet precautions is anticipated as it is a standard practice to prevent infection, especially in immunocompromised patients like those undergoing chemotherapy.
A private room is also anticipated to reduce the risk of infection and provide a controlled environment for the patient's comfort and monitoring.
The insertion of an indwelling urinary catheter may be nonessential unless there is a specific indication, such as urinary retention or close monitoring of output in a critically ill patient, as it can increase the risk of urinary tract infections.
Checking the client's rectal temperature once daily could be contraindicated due to the risk of causing trauma or bleeding, especially considering the client's decreased platelet count, which could lead to increased bleeding risk.
Lastly, rinsing the client's mouth with 0.9% sodium chloride every 4 hours is anticipated to help manage the sore mouth, a common side effect of chemotherapy, and to maintain oral hygiene, which is crucial in preventing infections in immunocompromised patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Labrynthitis is an inner ear disorder that causes vertigo, tinnitus, and hearing loss, but it does not typically involve otorrhea (ear discharge) or the sudden resolution of ear pain.
B. A perforated tympanic membrane is characterized by a sudden relief of ear pain when the eardrum ruptures, often accompanied by otorrhea (discharge from the ear). This condition is typically the result of an infection that increases pressure in the middle ear until the eardrum bursts.
C. Meniere disease involves episodes of vertigo, tinnitus, and fluctuating hearing loss, but does not usually present with ear pain followed by discharge.
D. Otitis externa, or swimmer’s ear, involves inflammation of the ear canal with symptoms like pain, itching, and discharge, but does not cause the sudden resolution of pain following the onset of otorrhea.
Correct Answer is C
Explanation
A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.
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