A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?

I might experience harmless white patches in my mouth.

I will expect to have a mild, occasional fever.

I will avoid people who have just received a live vaccine.

I will limit the use of skin cream to once a week.

Answer and Explanation

The Correct Answer is C

Choice A reason:

The statement “I might experience harmless white patches in my mouth” could indicate the presence of oral thrush, a common fungal infection in immunocompromised individuals. However, this statement does not directly reflect an understanding of preventive measures or home care instructions for someone with immunodeficiency.

Choice B reason:

Expecting to have a mild, occasional fever is not a typical understanding of immunodeficiency care. While fevers can occur, they should not be considered normal or expected. Any fever in an immunocompromised person should be promptly evaluated by a healthcare provider as it could indicate an infection.

Choice C reason:

Avoiding people who have just received a live vaccine is a crucial preventive measure for individuals with immunodeficiency. Live vaccines contain a weakened form of the virus or bacteria, which can pose a risk to immunocompromised individuals. This statement shows an understanding of the need to avoid potential sources of infection.

Choice D reason:

Limiting the use of skin cream to once a week is not a standard recommendation for immunodeficiency care. Skin care is important, but the frequency of using skin cream should be based on individual needs and the type of cream used. This statement does not reflect a specific understanding of immunodeficiency management.

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Correct Answer is B

Explanation

Choice A reason:

Applying a heat lamp twice a day is not recommended for treating stage 3 pressure ulcers. Heat lamps can cause burns and further damage to the already compromised skin. The primary goal in treating pressure ulcers is to reduce pressure, keep the area clean, and promote healing. Heat lamps do not contribute to these goals and can potentially worsen the condition.

Choice B reason:

Repositioning the client at least every 2 hours is a crucial intervention for managing stage 3 pressure ulcers. Frequent repositioning helps to alleviate pressure on the affected area, improving blood flow and preventing further tissue damage. This practice is essential in preventing the progression of pressure ulcers and promoting healing. It is one of the most effective strategies in pressure ulcer management.

Choice C reason:

Massaging reddened areas with dressing changes is not advisable. Massaging can cause additional trauma to the skin and underlying tissues, potentially worsening the ulcer. Instead, gentle handling and appropriate wound care techniques should be used to avoid further damage. Massaging can also disrupt the healing process and increase the risk of infection.

Choice D reason:

Cleaning the wound with hydrogen peroxide solution is not recommended for stage 3 pressure ulcers. Hydrogen peroxide can damage healthy tissue and delay the healing process. It is better to use saline or other wound cleaning solutions that are gentle and effective in removing debris without harming the tissue. Proper wound cleaning is essential to prevent infection and promote healing.

A. 90 bpm B. 100 bpm C. 110 bpm D. 120 bpm

Correct Answer is A

Explanation

Choice A reason: 90 bpm is the threshold below which the nurse should withhold digoxin for a 6-month-old infant. Digoxin can slow the heart rate, and administering it when the heart rate is already low can increase the risk of bradycardia, a serious heart rhythm disturbance.

Choice B reason: 100 bpm is above the threshold for withholding digoxin in a 6-month-old infant. While it is important to monitor the heart rate, digoxin can be safely administered if the apical heart rate is above 90 bpm.

Choice C reason: 110 bpm is also above the threshold for withholding digoxin. This heart rate indicates that the infant’s heart rate is within a safe range for administering the medication.

Choice D reason: 120 bpm is well above the threshold for withholding digoxin. This heart rate is considered safe for administering the medication, as it indicates the heart rate is not too low.

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A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate?

Correct Answer is A

Explanation

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