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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

Implement fall precautions for the client.

  • A. Implement fall precautions for the client. This is correct because risperidone can cause orthostatic hypotension, which can increase the risk of falls and injuries. The nurse should advise the client to change positions slowly, avoid alcohol and dehydration, and use assistive devices as needed.
  • B. Monitor the client's thyroid function. This is incorrect because risperidone does not affect thyroid function. The nurse should monitor the client's thyroid function if they are taking lithium, which can cause hypothyroidism.
  • C. Place the client on a fluid restriction. This is incorrect because risperidone does not cause fluid retention or overload. The nurse should encourage adequate fluid intake and monitor the client's fluid balance.
  • D. Discontinue the medication if hallucinations occur. This is incorrect because hallucinations are a symptom of schizophrenia, not a side effect of risperidone. The nurse should not discontinue the medication abruptly, as this can cause withdrawal symptoms and relapse of psychosis. The nurse should assess the client's response to the medication, report any adverse effects, and adjust the dosage as prescribed.

Correct Answer is D

Explanation

A. The nurse places the client on airborne precautions: This is appropriate, as measles is transmitted via airborne particles. B. The nurse has the client wear a mask for transport to radiology: This is correct. A surgical mask minimizes the risk of spreading airborne pathogens during transport. C. The nurse wears an N95 respirator when performing client care: Correct. An N95 respirator is necessary for protection against airborne diseases like measles. D. The nurse ensures the client's room maintains a positive airflow: This is incorrect and requires intervention. Clients with airborne infections like measles must be placed in negative pressure rooms, which prevent contaminated air from escaping into other areas. Positive airflow increases the risk of transmission to others.

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