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A nurse is caring for a client who has immunosuppression and a continuous IV infusion.

Which of the following actions should the nurse take?

A.

Assess the client's IV site every 8 hr.

B.

Check the client's WBC count every 48 hr.

C.

Monitor the client's mouth every 8 hr.

D.

Change the client's IV tubing every 48 hr.

Answer and Explanation

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 A

Explanation

Choice A rationale:

Preschoolers with celiac disease need to avoid gluten-containing grains such as wheat, barley, and rye. Corn tortilla with black beans is a suitable option as it does not contain gluten and provides essential nutrients.

Choice B rationale:

Whole wheat pasta contains gluten, which should be avoided by individuals with celiac disease. This option is inappropriate for the preschooler with celiac disease.

Choice C rationale:

Low sodium vegetable soup with barley contains gluten, which is not suitable for a child with celiac disease. Barley is a gluten-containing grain and should be avoided.

Choice D rationale:

Rye bread contains gluten and is not appropriate for a preschooler with celiac disease. This option is not suitable for the child's dietary needs.

Correct Answer is D

Explanation

Initiate transmission-based precautions.

Rationale:

  1. B- Encouraging oral fluids is an important intervention for a child who has a fever, as it helps prevent dehydration and electrolyte imbalance. However, it is not the priority intervention, as it does not address the risk of infection transmission to other clients or staff.
  2. A - Applying topical calamine lotion may help soothe the itching and discomfort caused by the vesicles, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
  3. C - Administering acetaminophen as an antipyretic may help reduce the fever and provide symptomatic relief for the child, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
  4. D - Initiating transmission-based precautions is the priority intervention, as it protects other clients and staff from exposure to the infectious agent that causes the vesicles and fever. The nurse should wear gloves, gown, mask, and eye protection when caring for the child, and place them in a private room or cohort them with other clients who have similar symptoms.

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