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 A
Explanation
A. Alopecia (hair loss) is a common manifestation of malnutrition. Protein deficiency, in particular, can lead to thinning hair or hair loss.
B. Diplopia (double vision) is not a typical manifestation of malnutrition. While malnutrition can affect vision in extreme cases, diplopia is more often associated with neurological or other systemic conditions.
C. Oily skin is not typically associated with malnutrition. In fact, malnutrition often leads to dry, flaky skin due to deficiencies in essential fatty acids and other nutrients.
D. Increased salivation is not a typical manifestation of malnutrition. It may occur in some specific conditions, but it is not commonly linked to malnutrition.
Correct Answer is C
Explanation
A. Increasing the room temperature may be necessary to prevent hypothermia, but the priority after securing the airway is fluid resuscitation to prevent shock and maintain circulation.
B. Administering analgesic medication is important for pain management but should not be the first intervention. Fluid resuscitation is the priority to stabilize the client’s condition.
C. The first priority in burn care after securing the airway is to start an IV with a large-bore needle to initiate fluid resuscitation. Burn victims are at high risk for fluid loss and hypovolemic shock, so IV fluids are crucial to maintain circulation and prevent organ failure.
D. Cleansing the wounds is important but should be done after stabilizing the client’s condition, particularly after fluid resuscitation.
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