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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Boiled eggs: While eggs contain some iron, the type is nonheme, and their consumption alone does not significantly enhance absorption. Eggs lack the vitamin C necessary to improve nonheme iron absorption from plant-based foods.

B. Cheddar cheese: Cheese contains minimal iron and is low in vitamin C. It does not aid in the absorption of nonheme iron and may actually inhibit iron absorption when consumed with iron-rich plant foods due to its high calcium content.

C. Mixed nuts: Nuts provide some nonheme iron, but they do not contain vitamin C to enhance absorption. Consuming nuts alone will not improve bioavailability of iron in a vegetarian diet.

D. Orange slices: Vitamin C in oranges significantly enhances the absorption of nonheme iron from plant-based foods by converting it into a more absorbable form. Including vitamin C-rich foods like oranges with meals helps increase iron uptake, which is particularly important for clients following vegetarian diets.

A. Provide 60 mL (2 oz) of fluid intake every 5 min. B. Ambulate the client 48 hr after the procedure. C. Provide a soft diet on the first postoperative day. D. Measure and compare abdominal girth daily.

Correct Answer is D

Explanation

Rationale:

A. Provide 60 mL (2 oz) of fluid intake every 5 min.: Following gastric bypass surgery, the stomach pouch is very small and cannot tolerate large or frequent volumes. Giving 60 mL every 5 minutes places the client at high risk for nausea, vomiting, dumping syndrome, and anastomotic complications. Fluid intake must be introduced slowly in small sips.

B. Ambulate the client 48 hr after the procedure.: Early ambulation is essential to prevent postoperative complications such as atelectasis, venous thromboembolism, and delayed return of bowel function. Waiting 48 hours is too long; clients should begin ambulating on the day of surgery or within the first 24 hours to promote circulation.

C. Provide a soft diet on the first postoperative day.: After gastric bypass surgery, the digestive system needs time to heal and cannot tolerate solid or semi-solid foods. Clients begin with clear liquids and progress gradually to pureed, soft, and then solid diets over several weeks.

D. Measure and compare abdominal girth daily.: Monitoring abdominal girth helps detect postoperative complications such as internal bleeding, leaks, or ileus, which may present with distention or increased abdominal size. Regular measurement provides early recognition of changes that require prompt intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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