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A nurse is creating a plan of care for an immunosuppressed client. Which of the following precautions should the nurse include in the plan? (Select All that Apply.)

Dispose all linen in trash after use

Don a mask, gloves, and gown

Restrict visitors who have active infections

Instruct the client to eat cooked foods only

Limit the client from bathing daily

Answer and Explanation

Correct Answer : B,C,D

A. Used linens do not need to be disposed of in the trash but should be laundered to prevent contamination.

B. Wearing a mask, gloves, and gown helps protect immunosuppressed clients from potential infections.

C. Restricting visitors who have active infections prevents the spread of infections to the client.

D. Instructing the client to eat only cooked foods reduces the risk of foodborne infections.

E. Limiting bathing is not necessary; in fact, good hygiene practices are essential to prevent infections.

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Correct Answer is C

Explanation

A. Checking for fecal impaction can help relieve the cause of autonomic dysreflexia but should be done after positioning the client.

B. Skin breakdown can trigger autonomic dysreflexia, but the immediate priority is to lower blood pressure by sitting the client up.

C. Placing the client in a sitting position helps lower blood pressure, which is the immediate concern in autonomic dysreflexia.

D. Checking for bladder distention is essential to find the trigger, but positioning comes first to manage the acute blood pressure elevation.

A. Platelet count B. Hemoglobin C. International normalized ration D. Atrial fibrillation E. Red blood cell count

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

Explanation

Platelet count: Low platelets (135,000/mm³) increase bleeding risk as they are essential for clot formation.

Hemoglobin: A hemoglobin level within the low normal range could increase the risk of hypoxemia, particularly in the perioperative period when oxygen demand may be higher.

INR: Elevated INR (1.5) indicates increased bleeding risk due to prolonged clotting time.

Atrial fibrillation: Increases the risk of DVT due to irregular heart rhythms, which can lead to blood pooling and clot formation.

RBC count: A low RBC count contributes to the risk of hypoxemia as there are fewer red blood cells available to transport oxygen.

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A nurse is creating a plan of care for an immunosuppressed client. Which of the following precautions should the nurse include in the plan? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client in the preoperative holding area. Exhibits For each preoperative assessment finding, click to specify if the assessment finding places the client at risk for hypoxemia, bleeding, or a DVT in the intra- op or post-op phases.

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

Explanation

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A nurse is creating a plan of care for an immunosuppressed client. Which of the following precautions should the nurse include in the plan? (Select All that Apply.)

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