The next 3 questions relate to this case study:

Exhibits

Select 4 appropriate interventions for the prevention and management of chemotherapy-induced nausea and vomiting (CINV) in Ms. Anderson.

Choice A: Masking before interviewing a patient about health history
Masking is generally used when there is a risk of exposure to respiratory droplets, such as when a patient has a known or suspected respiratory infection. However, it is not typically required for a standard health history interview unless there is a specific risk of exposure to infectious agents.
Choice B: Gloving before wiping pink sputum off the bedrail
This is the correct answer. Standard precautions include the use of personal protective equipment (PPE) such as gloves when there is a potential for contact with blood, body fluids, secretions, excretions, or contaminated items. Wiping pink sputum off the bedrail involves contact with potentially infectious material, making gloves necessary to prevent the spread of infection.
Choice C: Applying goggles before helping a patient to ambulate in the hall
Goggles or face shields are used when there is a risk of splashes or sprays of blood, body fluids, secretions, or excretions. Helping a patient to ambulate in the hall does not typically involve such risks, so goggles are not usually required in this scenario.
Choice D: Gowning prior to delivering a food tray to a patient
Gowns are used to protect skin and clothing from contamination when there is a risk of exposure to infectious material. Delivering a food tray to a patient does not generally pose such a risk, so gowning is not necessary for this task under standard precautions.

Choice A reason:

Watery diarrhea for 3 days is a significant finding that correlates with fluid and electrolyte imbalances. Diarrhea leads to the loss of fluids and electrolytes, which can result in dehydration and electrolyte disturbances such as hypokalemia or hyperkalemia. In this case, the patient’s potassium level is elevated (5.6 mEq/L), which could be a result of the body’s attempt to compensate for the loss of other electrolytes. Diarrhea also contributes to the patient’s weakness and lightheadedness due to dehydration.

Choice B reason:

Chronic kidney disease, which has been managed with diuretics and fluid restrictions, is another critical factor. Chronic kidney disease (CKD) affects the body’s ability to regulate fluid and electrolytes. The use of diuretics can exacerbate electrolyte imbalances, particularly potassium levels. In this scenario, the patient’s elevated potassium level (5.6 mEq/L) is concerning, as CKD patients are at higher risk for hyperkalemia due to decreased renal excretion of potassium. The combination of CKD and recent diarrhea increases the complexity of managing the patient’s fluid and electrolyte balance.

Choice C reason:

Lung sounds are clear is an important assessment finding but does not directly correlate with the primary nursing problem of fluid and electrolyte imbalance. While clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection, this finding does not address the immediate concerns related to fluid loss and electrolyte disturbances. Therefore, it is not a priority in this context.

Choice D reason:

No nausea and vomiting is a relevant finding but does not directly correlate with the primary nursing problem. The absence of nausea and vomiting is positive, as it indicates that the patient is not losing additional fluids and electrolytes through emesis. However, it does not address the significant fluid loss from diarrhea or the electrolyte imbalances that are the primary concerns in this scenario.

Choice E reason:

History of hypertension is a relevant factor in the patient’s overall health status. Hypertension can complicate the management of fluid and electrolyte imbalances, particularly in patients with CKD. The use of antihypertensive medications and diuretics can affect electrolyte levels and fluid balance. In this case, the patient’s blood pressure is slightly low (109/70), which could be related to dehydration from diarrhea and the effects of antihypertensive medications. This history is important for understanding the patient’s baseline and potential complications.

Choice F reason:

Blood urea nitrogen (BUN) is elevated at 30 mg/dL, which is above the normal range (6-24 mg/dL). An elevated BUN level indicates impaired kidney function and can be a sign of dehydration or renal insufficiency. In the context of CKD and recent diarrhea, an elevated BUN suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions.