A nurse is caring for a client who has immunosuppression and a continuous IV infusion.
Which of the following actions should the nurse take?
Assess the client's IV site every 8 hr.
Check the client's WBC count every 48 hr.
Monitor the client's mouth every 8 hr.
Change the client's IV tubing every 48 hr.
The Correct Answer is C
- A. Incorrect. The nurse should assess the client's IV site every hour to prevent infection and phlebitis.
- B. Incorrect. The nurse should check the client's WBC count every day to monitor for signs of infection or bone marrow suppression.
- C. Correct. The nurse should monitor the client's mouth every 8 hr for signs of oral candidiasis, which is a common fungal infection in immunosuppressed clients.\
- D. Incorrect. The nurse should change the client's IV tubing every 24 hr to reduce the risk of bacterial contamination.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The statement, "I will take the medication in the morning," indicates lack of understanding. Metformin is usually taken with large meals, and taking it in the morning is not the best timing.
Choice B rationale:
The statement, "I will expect to gain weight," is incorrect. Weight gain is not an expected side effect of metformin. In fact, metformin is often associated with weight loss or weight maintenance, especially in individuals with diabetes, as it helps improve insulin sensitivity and glucose metabolism.
Choice C rationale:
The statement, "I will take the medication on an empty stomach," is incorrect for extended-release metformin tablets. Unlike immediate-release metformin, extended-release tablets should be taken with meals to reduce the risk of gastrointestinal side effects.
Choice D rationale:
The statement, "I will avoid crushing this medication," is correct. Metformin extended-release tablets should never be crushed or broken, as it can affect the way the medication is released into the body. Crushing or breaking the tablet can lead to a sudden release of a large amount of metformin, potentially causing an overdose.
Correct Answer is C
Explanation
- A. Incorrect. The nurse should educate the parent on the importance of nebulizer treatments to deliver medications that thin and loosen mucus in the airways.
- B. Incorrect. The nurse should advise the parent to contact the provider if the child has a fever, which could indicate an infection or inflammation in the lungs.
- C. Correct. The nurse should initiate a request for a high-frequency chest compression vest, which is a device that vibrates the chest wall and helps mobilize mucus from the lungs.
- D. Incorrect. The nurse should encourage the parent to support the child's participation in team sports, which can improve lung function and social skills.
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