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 C

Explanation

A. Both fontanels show molding. Molding is seen immediately after birth due to the passage through the birth canal and should not be present at 8 months.
B. The posterior fontanel is open. The posterior fontanel usually closes by 2 to 3 months of age.
C. For an 8-month-old infant, it is normal for the anterior fontanel to still be open. It typically closes between 12 to 18 months of age.
D. Both fontanels are the same size. The anterior and posterior fontanels are naturally different sizes; the anterior is larger.

A. Place the bedside table at the foot of the bed. B. Assist the client to the toilet frequently C. Raise the side rails up when the client is in bed. D. Keep the television on during the night.

Correct Answer is B

Explanation

A: Placing the bedside table at the foot of the bed may not directly reduce the risk of injury for a client with dementia.
B: Assisting the client to the toilet frequently can prevent falls and accidents associated with incontinence, which are common concerns for clients with dementia.
C: Raising the side rails up can potentially increase the risk of injury if the client attempts to climb over them, leading to falls or entrapment.
D: Keeping the television on during the night may not directly address the risk of injury for the client.

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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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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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