A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)
Instruct the client to eat cooked foods only.
Restrict visitors who have active infections.
Dispose of all linen in the trash after use.
Limit the client from bathing daily.
Don a mask, gloves, and gown.
Correct Answer : A,B,E
Choice A reason:
Instructing the client to eat cooked foods only is a necessary precaution for immunosuppressed individuals. Cooking foods thoroughly can help eliminate harmful bacteria and other pathogens that could cause infection in a person with a weakened immune system.
Choice B reason:
Restricting visitors who have active infections is crucial in preventing the transmission of potentially harmful pathogens to the immunosuppressed client. Even minor infections in healthy individuals can be severe for someone with a compromised immune system.
Choice C reason:
Disposing of all linen in the trash after use is not a standard precaution for immunosuppressed clients. Used linens should be handled according to the healthcare facility's infection control policies, which often include laundering and not simply discarding in the trash.
Choice D reason:
Limiting the client from bathing daily is not a necessary precaution for immunosuppression. Maintaining good personal hygiene is important, and there is no need to restrict regular bathing unless there is a specific contraindication.
Choice E reason:
Donning a mask, gloves, and gown when caring for an immunosuppressed client can be part of standard precautions, especially if the client is in a protective environment or if the nurse is performing a procedure that has a high risk of contact with bodily fluids or if the client has a known infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Applying a foot plate to the bed is not primarily intended to prevent pressure points from developing around the edges of the splint. A foot plate can help in maintaining proper alignment and preventing foot drop, but it does not address the issue of pressure points caused by the splint.
Choice B reason:
Repositioning the client is a key intervention to prevent pressure points. By changing the client's position regularly, the nurse can ensure that no single area is under prolonged pressure, which could lead to skin breakdown and pressure sores. This is particularly important in clients with limited mobility due to skeletal traction.
Choice C reason:
Removing the weights for a few minutes each hour is not a standard practice for preventing pressure points in balanced skeletal traction. The weights are integral to maintaining the necessary pull on the fractured femur, and their removal could disrupt the traction setup and potentially affect fracture healing.
Choice D reason:
Applying lotion to the skin under the edges of the splint is not recommended as it could soften the skin and make it more susceptible to injury. Instead, padding and proper positioning are used to protect the skin from the hard edges of the splint.
Correct Answer is D
Explanation
Choice A reason:
While the white blood cell (WBC) count is important in assessing the immune system's ability to fight infection, a WBC of 5,000/mm³ is within the normal range (4,500 to 11,000 WBCs/mm³). Therefore, it is not the most critical value for a nurse to prioritize in the care of an HIV patient.
Choice B reason:
A platelet count of 150,000/mm³ is also within the normal range (150,000 to 450,000 platelets/mm³). Although thrombocytopenia can occur in HIV, this value does not indicate an immediate concern for the nurse to prioritize.
Choice C reason:
A positive Western blot test confirms the presence of HIV antibodies, which is indicative of HIV infection. However, this is a diagnostic result rather than a laboratory value that reflects the current status of the patient's immune function or disease progression.
Choice D reason:
The CD4-T-cell count is a critical laboratory value for assessing the immune function of a patient with HIV. A count of 180 cells/mm³ is below the normal range of 500 to 1,200 cells/mm³ and indicates a significantly weakened immune system, placing the patient at risk for opportunistic infections. This value is a priority as it guides treatment decisions and the need for prophylaxis against opportunistic infections.
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