A nurse is creating a plan of care for an immunosuppressed client. Which of the following precautions should the nurse include in the plan? (Select All that Apply.)
Dispose all linen in trash after use
Don a mask, gloves, and gown
Restrict visitors who have active infections
Instruct the client to eat cooked foods only
Limit the client from bathing daily
Correct Answer : B,C,D
A. Used linens do not need to be disposed of in the trash but should be laundered to prevent contamination.
B. Wearing a mask, gloves, and gown helps protect immunosuppressed clients from potential infections.
C. Restricting visitors who have active infections prevents the spread of infections to the client.
D. Instructing the client to eat only cooked foods reduces the risk of foodborne infections.
E. Limiting bathing is not necessary; in fact, good hygiene practices are essential to prevent infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Raising the foot of the bed to a 90° angle is not an appropriate intervention for a chest wound as it may impair respiratory function further.
B. Preparing to insert a central line is not a priority action in managing a sucking chest wound and may delay more immediate life-saving interventions.
C. Removing the dressing to inspect the wound can worsen the condition by allowing more air to enter, increasing the risk of a tension pneumothorax.
D. Administering oxygen via nasal cannula provides essential oxygen support, addressing hypoxia caused by the impaired respiratory function from the chest wound.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Option 1: Intracranial hemorrhage: The client’s recent fall, worsening headache, unilateral pupil dilation, right-sided weakness, and decreasing Glasgow Coma Scale (GCS) indicate a potential neurological injury, which is concerning for intracranial hemorrhage.
Option 2: Glasgow Coma Scale: The client's GCS has progressively declined (from 15 to 13), indicating a decrease in neurological function, which is critical in assessing intracranial pressure and risk for hemorrhage.
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