A nurse is creating a plan of care for a client who has cancer and is experiencing Immunosuppression. Which of the following Interventions should the nurse include in the plan of care?
Monitor the client's vital signs every 12 hr.
Inspect the client's mouth every 8 hr.
Provide fresh fruit with the client's meals.
Rotate health care staff caring for the client.
The Correct Answer is B
A. Monitoring vital signs every 12 hours is a standard nursing intervention but may not specifically address the needs of a client with immunosuppression.
B. Inspecting the client's mouth every 8 hours can help in early detection of mouth sores or infections, which are common in immunosuppressed individuals.
C. Providing fresh fruit with meals may not be appropriate for a client with immunosuppression, as fresh fruits can harbor pathogens that pose a risk of infection.
D. Rotating healthcare staff caring for the client helps increases the risk of introducing pathogens to the client. This increases the risk of infection in the immunosuppressed client.
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Related Questions
Correct Answer is C
Explanation
A. Informing the client that the transfusion is mandatory disregards the client's autonomy and right to refuse treatment.
B. While documenting the client's refusal is important, notifying risk management about the refusal is not necessary unless there are specific facility policies or legal requirements.
C. Documenting the client's refusal in the medical record ensures that the refusal is properly recorded and communicated to the healthcare team, protecting both the client's autonomy and the healthcare provider.
D. While it's important to respect the client's autonomy, suggesting alternative therapies may not be appropriate in this context and could undermine the client's decision-making process.
Correct Answer is C
Explanation
A. Using a child as an interpreter can be inappropriate and may not ensure accurate communication, especially for sensitive topics such as medical history and symptoms.
B. While involving the client's partner may seem helpful, it may not ensure accurate translation, and the partner may not be proficient in medical terminology.
C. Requesting a female interpreter through the facility ensures accurate and confidential communication while respecting the client's cultural preferences and privacy.
D. While asking a nursing student who speaks the same language as the client may seem convenient, it may not ensure accurate translation, and the student may not have the necessary training in medical interpretation.
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