A nurse is caring for a client who is suspected to have developed sensitivity to latex.
Which of the following interventions should the nurse plan to implement?
Use a disposable adhesive probe when measuring the client's SaO2
Wrap a blood pressure cuff in a stockinette for use in the client's room.
Document in the medical record that the client should not use silicone products.
Clean vial stoppers for 15 seconds before using them to withdraw-medications for the client.
The Correct Answer is B
Choice A rationale:
Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.
Choice B rationale:
Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.
Choice C rationale:
Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.
Choice D rationale:
Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Children with autism spectrum disorder often have difficulty with transitions and new situations. Introducing new situations slowly can help reduce anxiety and support a smoother adjustment.
Choice B rationale:
Administering valproic acid is not a nursing intervention for autism spectrum disorder.
Choice C rationale:
Allowing the toddler to choose the daily routine might not be effective as they may struggle with decision-making and may prefer structured routines.
Choice D rationale:
Increasing stimulation in the toddler's environment might overwhelm a child with autism, who often prefers a calm and predictable environment.
Correct Answer is B
Explanation
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
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