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.
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Related Questions
Correct Answer is B
Explanation
- A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.
- B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.
- C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.
- D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.
Correct Answer is A
Explanation
Hospice care includes bereavement support for the family for up to a year after the client's death.
- B is incorrect because the hospice nurse does not administer pain medication, but rather teaches the family how to manage the client's pain at home.
- C is incorrect because respite care is one of the services that hospice provides to allow the family to take a break from caregiving.
- D is incorrect because hospice care does not aim to prolong life, but rather to provide comfort and quality of life for the client and the family.
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