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 A
Explanation
A. Encouraging the use of assistive devices like canes can help improve stability and prevent falls in individuals with multiple sclerosis who may experience balance issues. This statement promotes safety and independence in mobility.
B. While exercise is beneficial for individuals with multiple sclerosis, recommending a rigorous program may not be appropriate initially and could potentially exacerbate symptoms.
C. Hot baths can exacerbate symptoms in individuals with multiple sclerosis due to heat sensitivity, so this advice may not be suitable.
D. Scatter rugs can pose a tripping hazard, especially for individuals with mobility issues, so this statement is incorrect and may increase the risk of falls.
Correct Answer is C
Explanation
A. Eating a meal before postural drainage could increase the risk of aspiration during the procedure.
B. Completing oral hygiene is good practice but not directly related to postural drainage.
C. Albuterol can help open the airways, making the postural drainage process more effective.
D. Pancrelipase is a medication to aid in digestion and is not directly related to the initiation of postural drainage.
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