A nurse is caring for a client who is receiving positive pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply)

 

Choice A reason:

The statement “I might experience harmless white patches in my mouth” could indicate the presence of oral thrush, a common fungal infection in immunocompromised individuals. However, this statement does not directly reflect an understanding of preventive measures or home care instructions for someone with immunodeficiency.

Choice B reason:

Expecting to have a mild, occasional fever is not a typical understanding of immunodeficiency care. While fevers can occur, they should not be considered normal or expected. Any fever in an immunocompromised person should be promptly evaluated by a healthcare provider as it could indicate an infection.

Choice C reason:

Avoiding people who have just received a live vaccine is a crucial preventive measure for individuals with immunodeficiency. Live vaccines contain a weakened form of the virus or bacteria, which can pose a risk to immunocompromised individuals. This statement shows an understanding of the need to avoid potential sources of infection.

Choice D reason:

Limiting the use of skin cream to once a week is not a standard recommendation for immunodeficiency care. Skin care is important, but the frequency of using skin cream should be based on individual needs and the type of cream used. This statement does not reflect a specific understanding of immunodeficiency management.

Choice A reason:

Monitoring the client’s calf for edema is important in assessing for complications such as deep vein thrombosis (DVT) or compartment syndrome, but it is not the primary technique for assessing neurovascular status. Edema can indicate fluid accumulation and potential vascular issues, but it does not directly assess the nerve function or blood flow to the extremity.

Choice B reason:

Palpating the femoral pulse is crucial in assessing the neurovascular status of a client with a femur fracture. The femoral pulse provides information about the blood flow to the lower extremity. A strong, palpable pulse indicates good arterial blood flow, while a weak or absent pulse may suggest vascular compromise, which requires immediate attention. This assessment helps ensure that the blood supply to the limb is adequate, which is vital for healing and preventing complications.

Choice C reason:

Measuring the circumference of the thigh can help monitor for swelling and changes in muscle mass, but it is not a direct assessment of neurovascular status. While it can provide useful information about the extent of swelling or atrophy, it does not evaluate the nerve function or blood flow directly.

Choice D reason:

Instructing the client to wiggle his toes is a useful technique to assess motor function and nerve integrity. However, it is not sufficient on its own to assess the entire neurovascular status. It should be part of a comprehensive assessment that includes checking pulses, sensation, and capillary refill.