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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Determine the need for additional providers: Determining the need for additional providers is typically the responsibility of the hospital administration or incident command team, not the unit nurse.

B. Act as a spokesperson to provide information to the media: Communication with the media is managed by designated public relations personnel or a hospital spokesperson, not the unit nurse.

C. Recommend to the provider a list of clients for early discharge: The unit nurse is responsible for assessing which clients are stable enough for discharge and communicating these recommendations to the provider. This helps prioritize bed availability and ensures appropriate allocation of resources during a disaster.

D. Decide which clients should be transported for a higher level of care: This decision is typically made by the disaster management team or the provider, with input from the nurse. Nurses may report clinical details to help inform the decision but do not make the final determination.

A. Apply lotion to skin every 4 hr. B. Supplement feeding with sterile water. C. Brestfeed every 2 to 3 hr. D. Cover newborn's eyes with a shield. E. Dress in only a diaper.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A. Applying lotion to the skin is contraindicated during phototherapy because it can interfere with the effectiveness of the therapy by blocking the light from reaching the skin. B. Supplementing feeding with sterile water is contraindicated because it can decrease the newborn's intake of breast milk or formula, which is essential for hydration and nutrition, especially during phototherapy. C. Breastfeeding is indicated and encouraged every 2 to 3 hours because it helps to maintain hydration and promotes bilirubin excretion, which can help in reducing jaundice levels. D. Covering the newborn's eyes with a shield is indicated during phototherapy to protect the eyes from the bright lights used in the treatment, which can potentially damage the retina and cause eye problems. E. Dressing the newborn in only a diaper is indicated during phototherapy to maximize the exposure of the skin to the light, which enhances the effectiveness of the treatment in reducing bilirubin levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster?

Correct Answer is C

Explanation

A nurse is caring for a 36-hr old infant. Exhibits For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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