While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?
Initiation of changes in infection control measures
Increasing the client's dietary servings of fruits and vegetables
Limiting the client's fluid intake to avoid hemodilution
Avoiding the client's exposure to cold temperatures
The Correct Answer is A
- Anti-Glycan Neu5Gc Antibodies (AGNA) are antibodies that recognize a carbohydrate antigen called N- glycolylneuraminic acid (Neu5Gc), which is found in animal-derived foods and tissues, but not in humans. Humans can incorporate Neu5Gc from their diet into their own cells, which can trigger an immune response and the production of AGNA.
- AGNA have been associated with various inflammatory and autoimmune diseases, such as atherosclerosis, rheumatoid arthritis, Crohn's disease, and cancer. AGNA may also play a role in the rejection of bioprosthetic heart valves, which are made from animal tissues that contain Neu5Gc.
- A client with carcinoma in situ of the left breast is a client with a non-invasive form of breast cancer, where the abnormal cells are confined to the ducts or lobules of the breast. This type of cancer has a high chance of cure with surgery and/or radiation therapy.
- Increased levels of AGNA in a client with carcinoma in situ of the left breast may indicate that the client has an increased risk of inflammation and infection, as AGNA can activate the complement system and recruit inflammatory cells to the site of Neu5Gc expression. This may impair the healing process and increase the chances of complications after surgery or radiation therapy.
Therefore, the practical nurse (PN) should anticipate that the client's plan of care will include initiation of changes in infection control measures, such as prophylactic antibiotics, wound care, sterile dressing changes, and monitoring for signs and symptoms of infection (such as fever, redness, swelling, pain, or pus). These measures will help to prevent or treat any potential infection and promote wound healing.
Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because increasing the client's dietary servings of fruits and vegetables may not have a significant impact on the levels of AGNA or Neu5Gc in the client's body.
Option C is incorrect because limiting the client's fluid intake to avoid hemodilution may not be necessary or beneficial for the client's condition.
Option D is incorrect because avoiding the client's exposure to cold temperatures may not be relevant or helpful for the client's condition.
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Correct Answer is D
Explanation
Choice A reason
Ensuring that the client's family supports the provider's decision for surgery is not an appropriate action. While family support is essential in the decision-making process, the primary responsibility lies with the client's health care surrogate or designated decision-maker. The family's support is not a substitute for obtaining informed consent from the designated decision-maker.
Choice B reason
Sending the unsigned informed consent form to the facility's risk manager is not appropriate action. The nurse should not send an unsigned informed consent form to the facility's risk manager. Unsigned consent forms do not have any legal significance or validity. The nurse should work with the health care surrogate to ensure that the consent form is appropriately completed and signed.
Choice C reason
Determining if the procedure is medically necessary for the client is not appropriate action. While the medical necessity of the procedure is important, the decision about the procedure's necessity should be made by the medical team and discussed with the health care surrogate. The nurse's role is to facilitate communication and ensure that the surrogate is informed and involved in the decision-making process.
Choice D reason
When a client is in a coma and unable to provide informed consent, the health care surrogate or designated decision-maker becomes responsible for making medical decisions on behalf of the client. It is essential for the nurse to ensure that the health care surrogate is aware of the situation, understands the risks and benefits of the surgical procedure, and has provided informed consent on behalf of the client.
Correct Answer is D
Explanation
Option A is incorrect because enrolling the UAP in a hospital education class on conducting safe client care does not address the immediate problem or correct the error.
Option B-This would be inappropriate for oral care in an unconscious client as it increases the risk of aspiration.The side-lying position is safer for oral hygiene in unconscious clients.
Option C:While encouraging family participation can be beneficial, it is not the most immediate concern in this situation. The priority is ensuring safe and effective care, which the UAP is providing correctly.
Option D:The flat side-lying position is appropriate for an unconscious client during oral hygiene care. This position helps to prevent aspiration by allowing any secretions or fluids to drain out of the mouth rather than down the throat, which could happen if the client were in a Fowler's position. The presence of the emesis basin near the chin also indicates that the UAP is prepared to catch any fluids, further reducing the risk of aspiration
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