A nurse is caring for a client who is suspected to have developed sensitivity to latex.
Which of the following interventions should the nurse plan to implement?
Use a disposable adhesive probe when measuring the client's SaO2
Wrap a blood pressure cuff in a stockinette for use in the client's room.
Document in the medical record that the client should not use silicone products.
Clean vial stoppers for 15 seconds before using them to withdraw-medications for the client.
The Correct Answer is B
Choice A rationale:
Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.
Choice B rationale:
Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.
Choice C rationale:
Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.
Choice D rationale:
Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
Choice B rationale:
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Choice C rationale:
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
Choice D rationale:
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Correct Answer is A
Explanation
Choice A rationale:
Elevating the head of the bed can help prevent intracranial pressure by promoting venous drainage from the head.
Choice B rationale:
Premature newborns need to rest and conserve energy, so excessive stimulation every 2 hours is not recommended.
Choice C rationale:
Placing the newborn in a radiant warmer helps maintain a stable body temperature, but it does not directly address intracranial pressure.
Choice D rationale:
Administering hypertonic solution is not a standard intervention for decreasing intracranial pressure in a premature newborn.
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