A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range:
Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]
Review need for pneumococcal vaccine.
Implement bleeding precautions.
Place the client in protective isolation.
Assess vital signs every 4 hours.
The Correct Answer is C
C. An ANC of 500/mm3 (0.5 x 10/L) is indicative of severe neutropenia, which places the client at a significantly increased risk of developing infections due to the decreased ability of the immune system to fight off pathogens. Placing the client in protective isolation is essential to minimize the risk of exposure to infectious agents that could lead to severe infections
A. While reviewing the need for pneumococcal vaccine is important for preventing infections in immunocompromised clients, it may not be the most immediate priority in this scenario.
B. Implementing bleeding precautions is relevant for clients with thrombocytopenia but is not the most critical intervention for a client with severe neutropenia.
D. Assessing vital signs every 4 hours is a routine nursing intervention, but it may not directly address the heightened risk of infection associated with severe neutropenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Releasing traction to use a bedpan may cause pain and discomfort to the client and risk exacerbating the fracture or compromising the alignment needed for surgery.
B. Log rolling the client and placing adult disposable briefs beneath them may not be suitable because it involves movement that can disrupt traction and worsen the client's pain.
Additionally, disposable briefs may not adequately manage urinary output, especially for a client awaiting surgery.
C.While using a catheter can be an option, it is generally not the first intervention unless the client is unable to void by other means or has a specific indication for catheterization. It carries risks, including infection, and should be considered carefully.
D. The nurse can assist the client in using a urinal while ensuring that traction is maintained. This allows the client to urinate without disrupting the traction setup, minimizing the risk of complications associated with the fracture.
Correct Answer is D
Explanation
D. Swimming is a low-impact exercise that is gentle on the joints and can provide numerous benefits for individuals with osteoarthritis. The buoyancy of water reduces stress on the joints while allowing for a full range of motion, making swimming an ideal exercise for improving joint flexibility, muscle strength, and cardiovascular fitness without exacerbating symptoms of osteoarthritis. Additionally, swimming can help relieve joint pain and stiffness and improve overall physical function in older adults with osteoarthritis.
A. Jogging or running can place significant stress on the joints, particularly the knees and hips, which may exacerbate symptoms of osteoarthritis and increase the risk of joint injury. High- impact activities like jogging or running are generally not recommended for individuals with osteoarthritis, especially in weight-bearing joints.
B. While engaging in daily activities can provide some level of physical activity, it may not be sufficient for managing osteoarthritis symptoms or improving joint function. Older adults with osteoarthritis can benefit from structured exercise programs tailored to their needs, which may include a variety of exercises aimed at improving joint flexibility, strength, and overall physical function.
C. Tennis or racquetball are high-impact sports that involve repetitive movements and may exacerbate joint pain and stiffness in individuals with osteoarthritis, particularly in the wrists, elbows, and shoulders. Engaging in these activities can increase the risk of joint injury and may not be suitable for older adults with osteoarthritis.
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