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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason:
Keeping artificial nails trimmed is a recommended practice in healthcare settings to maintain effective hand hygiene. Long nails can harbor bacteria and make it difficult to clean hands thoroughly. However, the CDC does not provide specific guidelines on the length of artificial nails for healthcare workers.

Choice B reason:
When caring for a client with Clostridium difficile, it is recommended to wash hands with soap and water rather than using alcohol-based hand rubs. Alcohol-based hand rubs are not effective against C. difficile spores. Therefore, thorough handwashing with soap and water is necessary to remove spores.

Choice C reason:
Chlorhexidine is an antiseptic agent that provides broad-spectrum antimicrobial activity and is recommended for hand hygiene in certain situations, such as before invasive procedures or for clients who are immunosuppressed. It is effective against a wide range of bacteria, viruses, and fungi, making it a suitable choice for immunocompromised patients to reduce the risk of infection.

Choice D reason:
The use of alcohol-based hand rubs before administering eye drops is not specifically recommended. While hand hygiene is essential before any contact with a patient, there is no particular preference for alcohol-based hand rubs in this context. The primary concern is to ensure that hands are clean to prevent contamination of the eye drops or the patient's eyes.

A. pH 7.50, HCO₃⁻ 20 mEq/L, PaCO₂ 32 mm Hg B. pH 7.25, HCO₃⁻ 19 mEq/L, PaCO₂ 30 mm Hg C. pH 7.30, HCO₃⁻ 26 mEq/L, PaCO₂ 50 mm Hg D. pH 7.55, HCO₃⁻ 30 mEq/L, PaCO₂ 31 mm Hg

Correct Answer is B

Explanation

Choice A reason:
This choice suggests a pH of 7.50, which is indicative of alkalosis, and not typically expected in a client with chronic kidney disease (CKD). CKD often leads to metabolic acidosis due to the accumulation of acids in the body as the kidneys fail to excrete them. The HCO₃⁻ level of 20 mEq/L is slightly lower than the normal range (22-26 mEq/L), and the PaCO₂ of 32 mm Hg is within the normal range (35-45 mm Hg), but these values do not align with the expected acidosis associated with CKD.

Choice B reason:
This set of values is consistent with metabolic acidosis, which is commonly seen in clients with CKD. A pH of 7.25 indicates acidemia, and an HCO₃⁻ level of 19 mEq/L is below the normal range, suggesting a primary metabolic acidosis. The PaCO₂ of 30 mm Hg is at the lower end of the normal range, which may indicate a compensatory respiratory response to the metabolic acidosis.

Choice C reason:
A pH of 7.30, while on the lower side, is not as acidic as one would expect in a client with CKD. The HCO₃⁻ level of 26 mEq/L is within the normal range, and a PaCO₂ of 50 mm Hg suggests respiratory acidosis, which is not the primary disorder in CKD.

Choice D reason:
This choice indicates a pH of 7.55, which is too alkaline and not characteristic of CKD, where metabolic acidosis is the expected finding. An HCO₃⁻ level of 30 mEq/L is higher than the normal range, suggesting metabolic alkalosis. The PaCO₂ of 31 mm Hg is slightly below the normal range, possibly indicating a compensatory response, but it does not align with the metabolic acidosis typically seen in CKD.

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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.)

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