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 C

Explanation

Choice A rationale:
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
Choice B rationale:
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
Choice C rationale:
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
Choice D rationale:
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.

A. "I will wear gloves when I change my cat's litter box.". B. "I will take my temperature once each week.". C. "I will be able to attend my favorite singer's concert.". D. "I will allow my toothbrush to dry completely between each use.".

Correct Answer is A

Explanation

Choice A rationale:
Wearing gloves when changing the cat's litter box is essential during chemotherapy because some chemotherapy drugs can be excreted in bodily fluids, including feces. Protecting against direct contact with potentially harmful substances is crucial to minimize exposure risks.
Choice B rationale:
Taking the temperature once each week is not a relevant precaution during chemotherapy. Monitoring temperature is important, but it should be done more frequently, such as daily, as chemotherapy can cause immunosuppression, increasing the risk of infection.
Choice C rationale:
Being able to attend a concert is not related to precautions during chemotherapy. It is essential for clients undergoing chemotherapy to avoid large gatherings and events where they might be exposed to infections.
Choice D rationale:
Allowing the toothbrush to dry completely between each use is a good hygiene practice but not specifically related to chemotherapy precautions. Proper oral hygiene is essential during chemotherapy, but using a soft toothbrush and regularly replacing it are more relevant considerations.

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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

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