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    Ati nur 114 med surg 2 proctored exam

    A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

    Explanation & Rationale

    Rationale: A. Taking the client’s temperature once per shift is insufficient for a client with immunosuppression. These clients are at high risk for infection, and even a slight elevation in temperature may indicate sepsis. The nurse should monitor temperature at least every 4 hours or as ordered. B. Inserting an indwelling catheter increases the risk of infection and should be avoided unless absolutely necessary. Strict aseptic technique and minimal use of invasive devices are essential in immunocompromised clients. C. Limiting the number of health care workers entering the room is appropriate. It helps minimize the client’s exposure to potential pathogens. Infection prevention is a key priority for immunosuppressed clients, including maintaining a clean environment, enforcing hand hygiene, and restricting visitors with illness. D. Providing fresh fruit to avoid constipation is contraindicated because fresh, unpeeled, or unwashed produce may harbor bacteria or fungi that could cause infection. Instead, clients should eat cooked, canned, or peeled fruits and vegetables to reduce microbial risk.

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