A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply)

Schedule the client as the last surgery of the day.

Notify ancillary departments of the client's allergy.

Label the surgical suite as latex-free.

Provide powdered gloves for the staff's use.

Ensure a latex allergy cart is available.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale:

Scheduling the client as the last surgery of the day is not directly related to the client's latex allergy. It might not be feasible to always schedule the client last, and this action does not specifically address the client's needs related to latex exposure.

Choice B rationale:

Notifying ancillary departments of the client's latex allergy is an important step to ensure the client's safety during the surgical process. This action helps other departments prepare and prevent accidental latex exposure, which could trigger an allergic reaction in the client.

Choice C rationale:

Labeling the surgical suite as latex-free is crucial to preventing latex exposure during the surgery. It alerts all staff members entering the surgical suite about the presence of a latex-allergic patient and reminds them to take appropriate precautions.

Choice D rationale:

Providing powdered gloves for the staff's use is not recommended, as powdered gloves can actually carry latex proteins and increase the risk of latex exposure. Powdered gloves have been associated with allergic reactions, so it's important to avoid their use in a latex-sensitive environment.

Choice E rationale:

Ensuring a latex allergy cart is available is a proactive measure to have necessary equipment and supplies on hand in case of an allergic reaction. This cart would contain latex-free items and medications that can be used to manage an allergic reaction should it occur during or after surgery.

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Correct Answer is ["A"]

Explanation

The correct answer is Choice A.

Choice A rationale: Administering enoxaparin 40 mg subcutaneously in the deltoid site is incorrect. Enoxaparin is typically administered in the abdomen or thigh to ensure proper absorption and minimize the risk of injury. Administering it in the deltoid requires an incident report for protocol deviation.

Choice B rationale: Advancing the urinary catheter 18 cm (7 in) is standard practice for male clients to ensure the catheter reaches the bladder. There is no indication of error or the need for an incident report as this action follows proper procedure.

Choice C rationale: Cleansing a wound with 0.99% sodium chloride irrigation prior to collecting a specimen for culture is standard practice. This action ensures the wound is free from surface contaminants and does not necessitate an incident report.

Choice D rationale: Flushing the tubing of a continuous enteral feeding with 30 mL of water is standard practice to maintain patency and ensure the effectiveness of the feeding. This procedure follows guidelines and does not require an incident report.

A. A client who has dehydration with a urine output of 40 mL/hr. B. A client who has cancer and reports pain as 4 on a scale of 0 to 10. C. A client who has asthma and a respiratory rate of 40/min. D. A client who has diabetes mellitus and a fasting blood glucose of 100 mg/dL.

Correct Answer is C

Explanation

Choice A rationale:

Dehydration is a serious condition, and a urine output of 40 mL/hr is indicative of decreased renal perfusion and potential renal failure. However, this situation does not require immediate intervention compared to other choices.

Choice B rationale:

Pain management is important, and a pain score of 4 out of 10 indicates mild to moderate pain. While addressing pain is essential for the client's comfort, it is not an immediate priority compared to the situation presented in another choice.

Choice C rationale:

(Correct Choice) A respiratory rate of 40 breaths per minute in a client with asthma indicates severe respiratory distress. This client is at risk of respiratory failure and requires immediate assessment and intervention.

Choice D rationale:

A fasting blood glucose of 100 mg/dL in a client with diabetes mellitus is within a normal range and does not require immediate attention when compared to the urgent situation in another choice.

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A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply)

Nursing Test Bank

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Correct Answer is ["A"]

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Correct Answer is C

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A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply)