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 {"xRanges":[299.765625,329.765625],"yRanges":[366.609375,396.609375]}
Explanation
Choice A rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation).
Choice B rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation). It then decreases steadily at approximately 1 cm every 24 hours.
Choice C rationale: One-week post-partum, the fundal height should be about 7 cm below the umbilicus (belly button). This means that the uterus is still larger than normal, but it is contracting and healing. The fundal height may vary depending on factors such as the size and position of the baby, the amount of amniotic fluid, and the mother's body type.
Correct Answer is B
Explanation
Choice A rationale:
Increased thirst is a common manifestation during the dying process due to dehydration and reduced fluid intake.
Choice B rationale:
Decreased secretions can occur as the body's systems gradually shut down during the dying process.
Choice C rationale:
Flushing of the extremities, also known as mottling, can occur due to poor circulation as the body's systems shut down.
Choice D rationale:
Periods of apnea or irregular breathing patterns can occur as the body's respiratory system becomes less effective during the dying process.
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