A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

Remove the stopcocks from IV tubing.

Cleanse the stoppers with povidone-iodine before withdrawing the medication.

Ensure the gloves in the surgical suite are powdered gloves.

Schedule the client as the first surgical procedure of the day.

Answer and Explanation

The Correct Answer is D

Schedule the client as the first surgical procedure of the day.
When scheduling a surgical procedure for a patient with a latex allergy, it is recommended to schedule them as the first case of the day.
Choice A is wrong because removing the stopcocks from IV tubing does not address the issue of latex allergy.
Choice B is wrong because cleansing the stoppers with povidone-iodine before withdrawing medication does not address the issue of latex allergy.
Choice C is wrong because powdered gloves can contain latex and should be avoided for patients with a latex allergy.

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Correct Answer is D

Explanation

“Delirium has an abrupt onset.” Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of someone’s surroundings.
The disorder usually comes on fast — within hours or a few days.

Choice A is wrong because delirium does affect a client’s perception of her environment.
Choice B is wrong because delirium does not have a slow progression, but rather an abrupt onset.
Choice C is wrong because delirium can affect a client’s sleep cycle.

A. Gastric residual of 300 mL at the end of the shift. B. Weight gain of 0.91 kg (2 Ib) in 2 days. C. Blood glucose level of 110 mg/dL. D. Diarrhea one time in a 24-hr period.

Correct Answer is A

Explanation

Gastric residual of 300 mL at the end of the shift is an unexpected finding.
Gastric residual volume refers to the volume of fluid remaining in the stomach during enteral feeding.
A gastric residual volume of less than or equal to 500 mL every 6 hours is considered safe and indicates that the gastrointestinal tract is functioning.

Choice B is wrong because weight gain is expected during enteral feeding.
Choice C is wrong because a blood glucose level of 110 mg/dL is within the normal range.
Choice D is wrong because diarrhea can be a common side effect of enteral feeding.

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A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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