A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
Limit the number of health care workers entering the room.
Insert an indwelling catheter to monitor for sediment in the urine.
Take the client’s temperature once per shift
Provide the client with fresh fruit to avoid constipation
The Correct Answer is A
A. Limiting the number of health care workers entering the room helps reduce the risk of exposure to infections.
B. Inserting an indwelling catheter is not a routine intervention for immunosuppressed clients and may increase the risk of infection.
C. Monitoring temperature more frequently than once per shift is crucial to detect early signs of infection in immunosuppressed clients.
D. Fresh fruit may carry a risk of bacterial contamination, and caution should be exercised in providing it to immunosuppressed clients.
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Related Questions
Correct Answer is ["A","D"]
Explanation
A. Using clean technique helps prevent contamination during catheter dressing changes.
B. Changing the catheter dressing every 2 days may not be necessary, and frequency should be based on the facility's policy and the client's condition.
C. Povidone-iodine is not the recommended antiseptic for cleaning the access port.
Alcohol or chlorhexidine is typically recommended.
D. Proper hand hygiene is crucial to prevent introducing pathogens during catheter care.
E. Using friction when cleaning the access port is not a recommended practice and may cause damage. Cleaning should be done gently to avoid compromising the integrity of the site.
Correct Answer is A
Explanation
A. Lactated Ringer’s is the preferred fluid for fluid resuscitation in the first 24 hours after a burn injury as it helps replace lost fluids and electrolytes.
B. Dextrose 5% in water is not the primary fluid for burn resuscitation.
C. 0.9% sodium chloride may be used, but Lactated Ringer’s is often preferred.
D. Dextrose 5% in 0.9% sodium chloride is not the primary fluid for burn resuscitation.
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