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 D
Explanation
A. EMLA cream is used for pain relief and is not typically necessary for quick procedures like catheterization in toddlers.
B. This is not necessary for catheterization; it’s more relevant to a clean catch or midstream urine sample.
C. This size is too large for a toddler; smaller sizes, typically 5-8 French, are used for pediatric patients.
D. When performing a catheterization, especially in a sterile procedure like obtaining a urine culture, it is critical to wear sterile gloves to prevent infection
Correct Answer is A
Explanation
A: Methylphenidate should be taken preferably 30 to 45 minutes before meals to reduce the risk of stomach upset. Furthermore, food interferes with its absorption.
B: Administering methylphenidate at bedtime is incorrect because it is a stimulant and can interfere with sleep.
C: Avoiding foods containing tyramine is not relevant for methylphenidate; it is more commonly a concern with certain antidepressants such as MAO inhibitors.
D: There is no need to avoid excess sodium intake specifically related to methylphenidate usage; this advice does not pertain to the side effects or interactions of the medication.
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