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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Rationale:
A. Taking the medication 2 hours apart from calcium supplements is important, but the timing is not the primary instruction; the focus should be on the medication itself.
B. Levothyroxine should be taken on an empty stomach, ideally 30 to 60 minutes before breakfast, to enhance absorption.
C. Taking a double dose if a dose is missed can lead to toxicity; patients should be instructed to skip the missed dose and resume the regular schedule.
D. While taking the medication with a small sip of water is acceptable, it is not the most critical instruction for ensuring proper absorption and effectiveness of levothyroxine.
Correct Answer is A
Explanation
Rationale:
A. Having the client wear a surgical mask while being transported outside the room is essential to prevent the transmission of TB to others. This minimizes exposure to airborne droplets.
B. Wearing a surgical mask while providing care for the client is not sufficient for preventing TB transmission; an N95 respirator is required to protect healthcare workers from inhaling airborne particles.
C. While restricting visitors may help limit exposure, it is not the most effective preventive measure compared to ensuring that the client wears a mask when out of their room.
D. Initiating contact precautions is not necessary for TB, as it primarily requires airborne precautions. Airborne isolation precautions should be followed, including the use of N95 respirators for healthcare workers and appropriate ventilation.