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A nurse is caring for a client who has immunosuppression and a continuous IV infusion.

Which of the following actions should the nurse take?

A.

Assess the client's IV site every 8 hr.

B.

Check the client's WBC count every 48 hr.

C.

Monitor the client's mouth every 8 hr.

D.

Change the client's IV tubing every 48 hr.

Answer and Explanation

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 A

Explanation

The adolescent has not voided in 4 hr.

Rationale:

  • A. The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
  • B. The adolescent's blood pressure is 131/89 mm Hg. This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
  • C. The adolescent reports severe pain. This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
  • D.Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.

Correct Answer is A

Explanation

A. Performing gastrostomy feedings through an established gastrostomy tube is within the scope of practice for an AP, as it is a routine, non-complex task.
B. Evaluating the effectiveness of pain medication requires assessment skills, which fall under the nurse’s scope of practice.
C. Providing client care instructions requires nursing judgment and should be done by the nurse.
D. Teaching a client how to measure their blood pressure involves client education, which is the nurse’s responsibility.

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