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A nurse is caring for an immunocompromised client on chemotherapy. The family would like to visit. What teaching should the nurse provide to the family regarding protective isolation?

Visitors may bring a fruit basket to increase client's nutrition.

Visitors should be taught to refrain from bringing flowers.

A sick family member can visit as long as they wear a surgical mask.

All visitors must complete hand washing and wear an N95 mask.

Answer and Explanation

The Correct Answer is B

A reason:

Visitors may bring a fruit basket is incorrect. Fresh fruit can carry bacteria and should be avoided.

B reason:

Refraining from bringing flowers is correct. Flowers can carry bacteria and fungi, posing a risk to immunocompromised clients.

C reason:

A sick family member visiting, even with a mask, is incorrect. Sick visitors should avoid contact with immunocompromised clients to prevent infection.

D reason:

All visitors must complete hand washing, but wearing an N95 mask is not necessary unless specifically required. Standard masks are typically sufficient.

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Correct Answer is C

Explanation

A reason:

Determining the time the client last received pain medication is important, but it should be done after assessing the current pain level. The nurse needs to know the severity of the pain to decide the next steps.

B reason:

Measuring the client's vital signs, including temperature, is also important, especially to rule out complications like infection. However, addressing the client's immediate pain should take priority to provide relief and then proceed with further assessments.

C reason:

Asking the client to rate her pain on a scale from 0 to 10 is correct. This provides a clear understanding of the pain's intensity, which is essential for determining the appropriate intervention. It allows the nurse to gauge the severity of the pain and respond accordingly.

D reason:

Repositioning the client and offering a back rub can help alleviate discomfort, but these actions should follow the pain assessment to ensure the interventions are appropriate based on the pain's severity and nature.

A. Massage the skin over the client's bony prominences. B. Use a transfer device to lift the client up in bed. C. Elevate the head of the bed no more than 45 degrees. D. Apply cornstarch to keep sensitive skin areas dry.

Correct Answer is B

Explanation

A reason:

Massaging the skin over bony prominences is incorrect. This can cause damage to underlying tissues, particularly in areas at high risk for pressure ulcers.

B reason:

Using a transfer device to lift the client up in bed is correct. This helps to reduce friction and shear, which can contribute to skin breakdown and pressure ulcer development.

C reason:

Elevating the head of the bed no more than 45 degrees can help, but it is not as directly related to maintaining skin integrity as using a transfer device. Elevating the head too much can increase pressure on the sacrum and heels.

D reason:

Applying cornstarch is not recommended as it can promote fungal growth and irritation. Proper moisture management with barrier creams is more effective for keeping skin dry and intact.

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A nurse is caring for an immunocompromised client on chemotherapy. The family would like to visit. What teaching should the nurse provide to the family regarding protective isolation?

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Naxlex Comprehensive Predictor Exams

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