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.

Answer and Explanation

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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Correct Answer is D

Explanation

A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.

C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.

A. "Repeat the dose if your child vomits within 1 hour after taking the medication." B. "You can add the medication to a half-cup of your child's favorite juice" C. "Limit your child's potassium intake while she is taking this medication. D. "Have your child drink a small glass of water after swallowing the medication.

Correct Answer is D

Explanation

A. It's important not to repeat a dose of digoxin if vomited soon after administration due to the risk of toxicity. Instead, parents should contact their healthcare provider for guidance.
B. Mixing digoxin with a large volume of liquid can lead to inaccurate dosing if the child does not consume all the liquid.

C. Digoxin affects potassium levels in the heart muscle; thus, maintaining a normal dietary intake of potassium is important, not limiting it, as hypokalemia can increase the risk of digoxin toxicity.
D. Having water after taking digoxin helps ensure that the medication is swallowed completely and minimizes the risk of esophageal irritation. It aids in proper absorption of the drug.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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