A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?

Schedule the client for the last surgery of the day.

Place monitoring cords and tubes in a stockinette.

Choose rubber injection ports for fluid administration.

Have phenytoin IV readily available.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Scheduling the client for the last surgery of the day is not directly related to the client's latex allergy. Proper planning for surgery in a latex-allergic client involves addressing potential exposures to latex-containing products and minimizing the risk of allergic reactions.

Choice B rationale:

Placing monitoring cords and tubes in a stockinette can help create a barrier between the client's skin and the latex-containing products. This measure helps reduce the risk of direct contact with latex, which could trigger an allergic reaction in a latex-sensitive individual.

Choice C rationale:

Choosing rubber injection ports for fluid administration is not appropriate for a client with a latex allergy. Rubber products often contain latex, which can lead to an allergic reaction in susceptible individuals.

Choice D rationale:

Having phenytoin IV readily available is not directly relevant to a client with a latex allergy. Phenytoin is an antiepileptic medication and should be available for clients who require it, but it does not address the specific concern of latex exposure.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.

Choice B rationale:

Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.

Choice C rationale:

Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.

Choice D rationale:

There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.

A. "I will take three sitz baths a week to relieve my discomfort.". B. "I should cleanse my lesions with 1/2 strength peroxide.". C. "I will avoid sexual activity until my lesions are healed.". D. "I am not contagious once I begin antiviral medication.".

Correct Answer is C

Explanation

Choice A rationale:

Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.

Choice B rationale:

Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.

Choice C rationale:

"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.

Choice D rationale:

"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.

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A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to give a bed bath to a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is providing teaching to a female client who has herpes simplex virus type 2. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching?

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan of care?

A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

A nurse in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the earliest manifestation of a change in neurological status?

A nurse is providing information about maintaining a special diet with a client who has irritable bowel syndrome. Which of the following information should the nurse include?

A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse should identify that which of the following findings indicates that the client has developed a postoperative paralytic ileus?

A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?