Author Question: The nurse talks with a client who is receiving chemotherapy for colon cancer, discussing the ... (Read 63 times)

james0929 · **on:** Jul 22, 2018

The nurse talks with a client who is receiving chemotherapy for colon cancer, discussing the importance of handwashing and screening visitors who are ill. The client receives this instruction more than once.

The most important reason for the repetition of this instruction is that: 1. It is very important to protect visitors from infection by the client.
2. The client is unable to retain much information at this time.
3. The client is immunosuppressed, and more susceptible to infection.
4. The nurse is not aware the client has already received this information.

Question 2

The patient with which medical condition is least likely to have a nursing diagnosis of Ineffective Airway Clearance? The patient who has

a. hypertension c. Guillain-Barr syn-drome
b. just had major abdominal surgery d. scoliosis

vickyvicksss · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3. The client is immunosuppressed, and more susceptible to infection.

Rationale:
Chemotherapy has the effect of reducing the immune system response with decreased white blood cell and red blood cell counts. In combination with the general debilitation caused by the disease, this puts the client at great risk for increased infection. It is important that the client fully understand infection precautions, such as hand hygiene, screening ill visitors, and avoiding large crowds of people. Caution should be taken with coming in contact with young children who are more likely to have an infection. Cancer is not a contagious disease, so there is no need to protect visitors from infection. While the client may have diminished memory due to treatment, this is not the most important reason for repeating the instruction. The nurse's awareness of the client's previous teaching is not the most important reason for repeating the instruction.

Answer to Question 2

A
Ineffective Airway Clearance exists when the patient has difficulty maintaining a patent airway at any point along the airway. Causes include tongue obstruction from anesthesia or a disease process or condition that impacts the nerves of respiration.