A nurse is caring for a client who has immunosuppression and a continuous IV infusion.
Which of the following actions should the nurse take?
Assess the client's IV site every 8 hr.
Check the client's WBC count every 48 hr.
Monitor the client's mouth every 8 hr.
Change the client's IV tubing every 48 hr.
The Correct Answer is C
- A. Incorrect. The nurse should assess the client's IV site every hour to prevent infection and phlebitis.
- B. Incorrect. The nurse should check the client's WBC count every day to monitor for signs of infection or bone marrow suppression.
- C. Correct. The nurse should monitor the client's mouth every 8 hr for signs of oral candidiasis, which is a common fungal infection in immunosuppressed clients.\
- D. Incorrect. The nurse should change the client's IV tubing every 24 hr to reduce the risk of bacterial contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Preschoolers with celiac disease need to avoid gluten-containing grains such as wheat, barley, and rye. Corn tortilla with black beans is a suitable option as it does not contain gluten and provides essential nutrients.
Choice B rationale:
Whole wheat pasta contains gluten, which should be avoided by individuals with celiac disease. This option is inappropriate for the preschooler with celiac disease.
Choice C rationale:
Low sodium vegetable soup with barley contains gluten, which is not suitable for a child with celiac disease. Barley is a gluten-containing grain and should be avoided.
Choice D rationale:
Rye bread contains gluten and is not appropriate for a preschooler with celiac disease. This option is not suitable for the child's dietary needs.
Correct Answer is A
Explanation
- A. Autonomy is the ethical principle that respects the right of clients to make their own decisions and choices regarding their health care. Informed consent is a process that ensures that clients are fully informed of the benefits, risks, alternatives, and consequences of a proposed treatment or procedure, and that they voluntarily agree to it.
- B. Nonmaleficence is the ethical principle that obliges health care providers to do no harm to clients, either intentionally or unintentionally. Informed consent does not directly promote this principle, although it may help to prevent harm by disclosing potential risks and complications.
- C. Justice is the ethical principle that requires fair and equal treatment of all clients, regardless of their personal characteristics, preferences, or values. Informed consent does not directly promote this principle, although it may help to ensure that clients are not coerced or manipulated into accepting a treatment or procedure that they do not want or need.
- D. Fidelity is the ethical principle that requires health care providers to be faithful and loyal to their clients, and to honor their commitments and promises. Informed consent does not directly promote this principle, although it may help to establish trust and rapport between clients and providers.
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