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
Droplet.
The rationale for each choice is as follows:
- A. Droplet: Correct. Pneumonia is transmitted by respiratory droplets that are generated by coughing, sneezing, or talking. The nurse should wear a surgical mask and eye protection when caring for the client and maintain a distance of at least 3 feet from the client.
- B. Airborne: Incorrect. Airborne precautions are used for diseases that are transmitted by small particles that remain suspended in the air for long periods of time, such as tuberculosis, measles, or chickenpox. The nurse should wear a respirator and place the client in a negative-pressure room.
- C. Contact: Incorrect. Contact precautions are used for diseases that are transmitted by direct or indirect contact with the client or the client's environment, such as Clostridium difficile, scabies, or MRSA. The nurse should wear gloves and a gown and use dedicated equipment for the client.
- D. Protective environment: Incorrect. Protective environment precautions are used for clients who are immunocompromised and at risk of infection from others, such as clients who have had a stem cell transplant or are receiving chemotherapy. The nurse should wear a mask, gloves, and a gown and place the client in a positive-pressure room with HEPA filtration.
Correct Answer is C
Explanation
Choice A rationale:
Keeping a can of concentrated formula in the refrigerator for 3 days after opening it is not safe. Once a can of formula is opened, it should be used within 24 hours and stored in the refrigerator. After 24 hours, any leftover formula should be discarded to prevent the risk of bacterial contamination.
Choice B rationale:
Diluting ready-to-feed formula with water is incorrect. Ready-to-feed formula is already prepared and does not need to be diluted further. Adding water to ready-to-feed formula can dilute its nutritional content and may not provide the necessary nutrients for the baby.
Choice C rationale:
Boiling tap water for 2 minutes and cooling it before mixing it with powdered formula is the correct method for safe formula preparation. Boiling the water kills harmful bacteria and ensures the formula is safe for the baby to consume. It is essential to cool the boiled water before mixing it with powdered formula to reach an appropriate feeding temperature.
Choice D rationale:
Ensuring that all bottles contain BPA (bisphenol A) is not a relevant consideration for formula preparation. BPA is a chemical that was previously used in some plastics, including baby bottles, but has been banned in baby bottles and sippy cups in several countries due to its potential health risks. Most modern baby bottles are BPA-free, and this statement does not address the safe handling and preparation of formula for the baby.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.