A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.)
Instruct the client to eat cooked foods only.
Restrict visitors who have active infections.
Dispose of all linen in the trash after use.
Limit the client from bathing daily.
Don a mask, gloves, and gown.
Correct Answer : A,B,E
Choice A reason:
Instructing the client to eat cooked foods only is a necessary precaution for immunosuppressed individuals. Cooking foods thoroughly can help eliminate harmful bacteria and other pathogens that could cause infection in a person with a weakened immune system.
Choice B reason:
Restricting visitors who have active infections is crucial in preventing the transmission of potentially harmful pathogens to the immunosuppressed client. Even minor infections in healthy individuals can be severe for someone with a compromised immune system.
Choice C reason:
Disposing of all linen in the trash after use is not a standard precaution for immunosuppressed clients. Used linens should be handled according to the healthcare facility's infection control policies, which often include laundering and not simply discarding in the trash.
Choice D reason:
Limiting the client from bathing daily is not a necessary precaution for immunosuppression. Maintaining good personal hygiene is important, and there is no need to restrict regular bathing unless there is a specific contraindication.
Choice E reason:
Donning a mask, gloves, and gown when caring for an immunosuppressed client can be part of standard precautions, especially if the client is in a protective environment or if the nurse is performing a procedure that has a high risk of contact with bodily fluids or if the client has a known infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
The statement "This procedure is routinely performed during a Pap test" is incorrect. A colposcopy is not routinely performed during a Pap test; it is a separate procedure that is often recommended if a Pap test shows abnormal results. The colposcopy allows for a closer examination of the cervix, vagina, and vulva to detect any signs of disease.
Choice B reason:
The statement "During the procedure, a biopsy may be performed" is correct. If the healthcare provider sees an area of concern during the colposcopy, they may take a small sample of tissue (biopsy) from the cervix or from inside the opening of the cervix.
Choice C reason:
The statement "Do not eat or drink after midnight tonight" is not necessary for a colposcopy. Unlike some surgical procedures that require general anesthesia, a colposcopy is usually done with local anesthesia, and fasting is not required.
Choice D reason:
The statement "You will have general anesthesia during this procedure" is incorrect. General anesthesia is not typically used for a colposcopy. The procedure may cause some discomfort, but it is usually performed using local anesthesia or no anesthesia at all.
Correct Answer is C
Explanation
Choice A reason:
Hay fever allergy, also known as allergic rhinitis, is primarily associated with the action of Immunoglobulin E (IgE) antibodies and not directly with T-cells. T-cells can contribute to the regulation of the immune response in allergies, but IgE is the main immunoglobulin involved in the typical symptoms of hay fever.
Choice B reason:
Anaphylaxis is a severe, potentially life-threatening allergic reaction that involves the release of large amounts of histamine and other chemicals from mast cells and basophils, often triggered by IgE antibodies. While T-cells can play a role in the sensitization phase of allergy, anaphylaxis itself is not directly caused by T-cells.
Choice C reason:
Transplant rejection is a process in which T-cells play a central role. When a transplant recipient's immune system recognizes the donated organ as foreign, T-cells can mediate the rejection by attacking the transplanted tissue, leading to its failure.
Choice D reason:
Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. T-cells are involved in the adaptive immune response and can activate phagocytes, but they do not directly perform phagocytosis.
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