A nurse is creating a plan of care for a client who has cancer and is experiencing Immunosuppression. Which of the following Interventions should the nurse include in the plan of care?
Monitor the client's vital signs every 12 hr.
Inspect the client's mouth every 8 hr.
Provide fresh fruit with the client's meals.
Rotate health care staff caring for the client.
The Correct Answer is B
A. Monitoring vital signs every 12 hours is a standard nursing intervention but may not specifically address the needs of a client with immunosuppression.
B. Inspecting the client's mouth every 8 hours can help in early detection of mouth sores or infections, which are common in immunosuppressed individuals.
C. Providing fresh fruit with meals may not be appropriate for a client with immunosuppression, as fresh fruits can harbor pathogens that pose a risk of infection.
D. Rotating healthcare staff caring for the client helps increases the risk of introducing pathogens to the client. This increases the risk of infection in the immunosuppressed client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential condition:
The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.
The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.
Action to take:
In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.
Parameters to monitor:
To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.
Correct Answer is C
Explanation
A. Negligence refers to the failure to provide care that a reasonably prudent person would have under similar circumstances, resulting in harm to the patient.
B. Battery involves the intentional harmful or offensive contact with a person without their consent. While similar to assault, battery involves actual physical contact, such as forcibly inserting a urinary catheter without consent.
C. Assault occurs when a threat of harmful or offensive contact is made, causing fear or apprehension in the victim. In this scenario, the newly licensed nurse's statement of
inserting a urinary catheter without consent if the client does not void constitutes an act of assault.
D. Libel involves making defamatory statements in written or published form, which is not applicable in this scenario.
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