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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

C. Breakthrough pain is a transient exacerbation of pain that occurs despite the use of around- the-clock analgesics for persistent pain. Breakthrough pain episodes require rapid intervention with additional analgesics or adjustments to the current pain management regimen to provide adequate pain relief and improve the client's quality of life.
A. Replacing transdermal analgesic patches every 72 hours is important for ensuring consistent delivery of medication, but it is not directly related to addressing breakthrough pain.
B. Administering analgesics on a fixed and continuous schedule is important for maintaining baseline pain control, but it may not address breakthrough pain adequately.
D. Frequently evaluating the client's pain is essential, but monitoring specifically for breakthrough pain ensures timely intervention when pain exacerbations occur.

A. Restrict physical activities. B. Use incentive spirometer. C. Report when hematuria becomes pink tinged. D. Monitor urinary stream for decrease in output.

Correct Answer is D

Explanation

A. Complete restriction of physical activities is not necessary. The nurse should provide guidance on gradually resuming normal activities based on the healthcare provider's recommendations.

B. Incentive spirometer is not directly related to the management or recovery following TUNA for BPH. This device is typically used to improve lung function and prevent respiratory complications, which may not be a primary concern in this scenario.

C.While clients should monitor hematuria, the primary focus post-TUNA is on urinary output and function rather than just the color of the urine. Changes in hematuria color are important, but they may not directly correlate to urgent issues.
D. After TUNA, clients need to be vigilant about their urinary output because a decrease can indicate complications such as re-obstruction, which is a significant concern following the procedure. Monitoring urinary stream is essential for detecting potential issues early, making this the best choice for discharge instructions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

Correct Answer is D

Explanation

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound lendemess. Which action should the nurse take?

Patient Data Exhibits Review H and P, nurse's note, and laboratory results. What other nutritional recommendation(s) would be helpful for this client in reducing risk for type 2 diabetes mellitus? Select all that apply.

The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding is most important for the nurse to monitor?

After initiating a steroid nebulizer treatment for a client with asthma in respiratory distress, which intervention is most important for the nurse to implement?

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)]