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 A

Explanation

A. For clients receiving hemodialysis, maintaining adequate protein intake is essential because dialysis can remove protein from the blood. The recommended intake is typically about 1 g/kg/day, which helps replace losses and supports overall health.
B. Consume foods high in potassium. Clients with chronic kidney disease often need to restrict potassium intake due to impaired kidney function and the risk of hyperkalemia.
C. Take magnesium hydroxide for indigestion. Clients with chronic kidney disease should avoid magnesium-containing antacids due to the risk of magnesium accumulation and toxicity.
D. Drink at least 3 L of fluid daily. Fluid intake usually needs to be restricted in clients undergoing hemodialysis because their kidneys cannot effectively remove excess fluid, which can lead to complications like hypertension and pulmonary edema.

A. Clonazepam B. Carbamazepine C. Lamotrigine D. Lorazepam

Correct Answer is D

Explanation

A. Clonazepam. While also a benzodiazepine, it is not typically the first choice for immediate management of status epilepticus.

B. Carbamazepine. Used for chronic management of seizures, not for acute seizure episodes like status epilepticus.
C. Lamotrigine. Also used for long-term seizure management and not suitable for acute intervention in status epilepticus.
D. Lorazepam is a benzodiazepine used as a first-line treatment for status epilepticus due to its rapid onset of action and efficacy in stopping seizures quickly.

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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

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