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 ["C","D","E"]
Explanation
Rationale for correct choices
• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.
• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.
• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.
Rationale for incorrect choices
• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.
• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices
- Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
- Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.
Rationale for Incorrect Choices
- Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
- Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
- Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.
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