A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following strategies is appropriate for this client?
Remove stopcocks from IV tubing
Disinfect and powder any latex products before use.
Tape stockinet over monitoring devices and cords.
Schedule the client as the last surgery of the day.
The Correct Answer is C
Rationale:
A. Remove stopcocks from IV tubing: Removing stopcocks is not necessary and may compromise IV line function. The priority is to prevent contact with latex-containing components, not to eliminate all IV hardware, as many are latex-free.
B. Disinfect and powder any latex products before use: Powdered latex products increase the risk of airborne latex particles, which can trigger severe allergic reactions. Disinfecting or using powdered latex items is unsafe for clients with latex sensitivity and should be avoided entirely.
C. Tape stockinet over monitoring devices and cords: Covering monitoring devices, cords, and other equipment with a barrier such as stockinet prevents direct contact with latex-containing components. This reduces the risk of an allergic reaction during surgery while allowing the necessary monitoring and functionality to continue safely.
D. Schedule the client as the last surgery of the day: While scheduling considerations may be made to reduce exposure to residual latex or disinfectants, the timing of surgery is not the primary strategy for preventing a reaction. The focus should be on removing or isolating all latex-containing items from the environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Provide the client with a stool softener: Clients with thrombocytopenia are at increased risk for bleeding, including gastrointestinal bleeding. Hard stools can cause straining during defecation, which may lead to rectal bleeding. Administering a stool softener helps prevent constipation and reduces the risk of bleeding from the gastrointestinal tract.
B. Remove fresh flowers from the client's room: This intervention is appropriate for clients who are immunocompromised to prevent infection, but it is not specifically necessary for thrombocytopenia unless the client also has neutropenia. The main concern in thrombocytopenia is bleeding, not infection.
C. Avoid serving the client raw vegetables: While raw vegetables may carry a risk of infection, thrombocytopenia alone does not require dietary restrictions for raw vegetables. Safe food handling is important, but preventing bleeding is the primary focus of care.
D. Encourage the client to floss daily: Flossing can increase the risk of gum bleeding in clients with thrombocytopenia. Oral hygiene should be maintained gently with soft-bristled toothbrushes, but daily flossing is not recommended because it may cause unnecessary bleeding.
Correct Answer is C
Explanation
Rationale:
A. WBC count 10,000/mm³ (5,000 to 10,000/mm³): This value is at the upper limit of normal. Mild elevations can occur during early pregnancy due to physiological changes and do not typically require immediate reporting unless accompanied by signs of infection.
B. Fasting blood glucose 80 mg/dL (74 to 106 mg/dL): This value falls within the normal fasting glucose range for adults and is not concerning during early pregnancy. No intervention or reporting is necessary for this result.
C. Hematocrit 30% (37% to 47%): This value is below the normal range, indicating anemia. Early pregnancy anemia can increase the risk of maternal fatigue, preterm birth, and low birth weight. The nurse should report this finding to the provider for further evaluation and possible iron supplementation.
D. RBC count 6 million/mm³ (4.2 to 6.1 million/mm³): This value is within the normal range for red blood cells. It does not indicate any immediate concern and does not require reporting to the provider.
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