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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

The sodium level of 140 mEq/L is within the normal range for children, which is 135 to 145 mEq/L. Sodium levels may be low in nephrotic syndrome due to fluid retention and dilutional hyponatremia, but this is not the case for this child.

Choice B rationale:

The platelet count of 350,000/mm3 is within the normal range for children, which is 150,000 to 450,000/mm3. Platelet levels may be elevated in nephrotic syndrome due to increased production by the bone marrow in response to inflammation and infection, but this is not the case for this child.

Choice C rationale:

The nurse should report the protein level of 2 g/dL to the provider, as this is abnormally low and indicates severe proteinuria. Proteinuria is a hallmark of nephrotic syndrome, as the glomeruli become damaged and allow protein to leak into the urine. Normal protein levels for children are 6 to 8 g/dL. Low protein levels can lead to edema, hypoalbuminemia, and hyperlipidemia.

Choice D rationale:

The cholesterol level of 170 mg/dL is within the normal range for children, which is less than 200 mg/dL. Cholesterol levels may be high in nephrotic syndrome due to increased synthesis by the liver as a compensatory mechanism for low protein levels, but this is not the case for this child.

A. 15 mL of drainage in Hemovac B. Periorbital ecchymosis C. Nonreactive pupils D. Hgb 11 g/dL

Correct Answer is C

Explanation

Choice A rationale:

Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.

Choice B rationale:

Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.

Choice C rationale:

Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.

Choice D rationale:

Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.

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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?

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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?