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.

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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Correct Answer is C

Explanation

- A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.

- B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.

- C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.

- D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.

A. "I can expect my eyelids to be bruised after this procedure.” B. "I will see dark spots in my vision after this procedure.” C. "I will receive general anesthesia for this procedure.” D. "I know the provider will replace the lens in my eyes during this procedure.”

Correct Answer is D

Explanation

Choice A rationale:

The statement, "I can expect my eyelids to be bruised after this procedure," indicates an understanding of the common side effects of cataract removal surgery. Bruising around the eyes is a common occurrence due to the manipulation of tissues during the procedure.

Choice B rationale:

The statement, "I will see dark spots in my vision after this procedure," is incorrect. Dark spots in vision are not a normal or expected outcome of cataract removal surgery. This statement shows a misunderstanding of the procedure.

Choice C rationale:

The statement, "I will receive general anesthesia for this procedure," is incorrect. While anesthesia is administered during the procedure, specifying the type of anesthesia is not crucial for the client's understanding of the surgery itself. The focus should be on the procedure details rather than the type of anesthesia.

Choice D rationale:

The statement, "I know the provider will replace the lens in my eyes during this procedure," indicates a clear understanding of the cataract removal procedure. The main goal of cataract surgery is to remove the cloudy lens and replace it with a clear artificial lens, improving the patient's vision. This statement demonstrates the client's comprehension of the surgery process.

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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?

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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?