A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant?
Dietary salt restriction
Absence of symptoms
Addition of a new medication
A detailed plan of care
The Correct Answer is B
Rationale:
A. Dietary salt restriction is challenging but is a specific intervention that can be managed with education and support.
B. The absence of symptoms can significantly hinder compliance because clients may not perceive the need to adhere to a treatment plan if they do not feel unwell. This perception can lead to underestimating the importance of managing their blood pressure.
C. The addition of a new medication may pose some challenges, but clients often adapt to new medications with proper guidance.
D. A detailed plan of care can enhance understanding and compliance, making it less likely to be a barrier compared to the lack of symptomatic cues indicating a need for treatment.
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Correct Answer is A
Explanation
Rationale:
A. Assessing the client's IV site every 8 hours is appropriate to prevent complications such as infection or infiltration, especially in an immunocompromised client.
B. Checking the client's WBC count every 48 hours is insufficient; it should be monitored more frequently due to the client's immunocompromised state.
C. Monitoring the client's mouth every 8 hours is necessary, but not as critical as regular IV site assessments.
D. Changing the client's tubing every 48 hours may not be necessary unless indicated by the facility's protocol or the client's condition; continuous IV tubing is typically changed every 72 to 96 hours unless there are signs of complications.
Correct Answer is B
Explanation
Rationale:
A. While restricting visits from young children may help reduce infection risk, it is not a sufficient or specific intervention for neutropenic precautions.
B. Avoiding raw fruits is critical because they can harbor bacteria and increase the risk of infection in neutropenic clients. Cooked fruits are safer options.
C. Measuring temperature should occur more frequently than every 8 hours, ideally every 4 hours or more, to quickly identify fever, a sign of infection.
D. Disposable gloves should be used from within the client's room to maintain strict infection control measures; using gloves from outside could introduce contaminants.