A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?
Assess the client's IV site every 8 hr.
Check the client's WBC count every 48 hr.
Monitor the client's mouth every 8 hr.
Change the client's tubing every 48 hr.
The Correct Answer is A
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.
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Correct Answer is D
Explanation
Rationale:
A. Providing interpretation services over the telephone is not effective for clients with hearing loss who may benefit more from in-person or visual communication.
B. Exaggerated lip movements can be distracting and may not aid understanding; clear and natural speech is more effective.
C. While providing written materials is helpful, ensuring the client can understand the material is key; using an appropriate reading level is essential but secondary to direct communication strategies.
D. Reducing environmental stimuli helps minimize distractions, making it easier for the client to focus on the nurse's speech or lip movements and improving overall communication.
Correct Answer is B
Explanation
Rationale:
A. Similar to the previous question, a quick inhalation is not recommended; the child should take a slow, deep breath for effective medication delivery.
B. Taking the medication 5 minutes before playing sports is ideal as it allows the medication to work quickly, ensuring better performance and control of asthma symptoms during activity.
C. Cleaning the mouthpiece with warm water every 2 weeks is insufficient; it should be cleaned more frequently, typically after each use, to maintain hygiene.
D. Waiting 10 seconds between inhalations is appropriate, but the focus on the timing before sports is critical for proper management of asthma symptoms.