A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?
"Wash your toothbrush in the dishwasher once each month."
"Change your pet's litter box daily."
"Change the water in your drinking glass every 4 hours."
"Wash your perineal area two times each day with antimicrobial soap."
The Correct Answer is C
A. The nurse should recommend that the client avoid using a toothbrush that is not regularly disinfected. However, washing the toothbrush in the dishwasher may not be sufficient. The client should replace the toothbrush regularly and disinfect it appropriately.
B. Changing the pet's litter box daily is not safe for clients with an impaired immune system. The nurse should advise the client to avoid cleaning the litter box or, if necessary, to wear gloves and a mask while performing the task, and ask someone else to do it if possible.
C. Changing the water in the drinking glass every 4 hours is an important infection control measure for clients with compromised immune systems. Stagnant water can promote bacterial growth, which poses an increased risk for infection in immunocompromised clients.
D. Washing the perineal area two times each day with antimicrobial soap is unnecessary and may cause irritation or disrupt the natural flora of the skin. The nurse should recommend gentle cleansing with mild soap and water instead. Overuse of antimicrobial products can lead to skin damage or resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Limiting fluid intake is not appropriate for preventing venous thromboembolism (VTE). Adequate hydration is important to maintain blood volume and prevent clot formation.
B. Massaging the client's legs is not recommended, as it can dislodge a clot if one is present, increasing the risk of embolism.
C. Encouraging circumduction of the feet (circular motion of the feet) helps improve circulation and prevent venous stasis, which is a key factor in the development of venous thromboembolism.
D. Keeping the client's knees in a flexed position can increase the risk of venous stasis and clot formation. The client should be encouraged to keep their legs straight and perform exercises to promote circulation.
Correct Answer is C
Explanation
A. The top of the ampule is broken off, not disposed of immediately. The broken glass should be disposed of properly in a sharps container after use.
B. Expelling air into the ampule is not a correct procedure. Air should be expelled from the syringe after withdrawing the medication, not into the ampule.
C. The nurse should place a paper towel around the neck of the ampule to protect themselves from breaking glass and use both hands to break off the top. This is the correct and safe method to open the ampule.
D. A needleless system is not used when withdrawing medication from an ampule. A regular syringe and needle are used, and care should be taken to avoid contamination when drawing up the medication.
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