A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10⁹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
Reference Range:
Neutrophils (ANC) [2500 to 5800/mm³ (2.5 to 5.8 x 10⁹/L)]

Review need for pneumococcal vaccine.

Implement bleeding precautions.

Assess vital signs every 4 hours.

Place the client in protective isolation.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect because reviewing the need for pneumococcal vaccine is not the most important intervention for the nurse to implement. Pneumococcal vaccine is recommended for people who are at high risk of pneumococcal infections, such as those with chronic diseases or immunosuppression. However, it is not a priority action for a client with neutropenia, which is a low number of neutrophils that increases the risk of bacterial and fungal infections.

Choice B reason: This is incorrect because implementing bleeding precautions is not the most important intervention for the nurse to implement. Bleeding precautions are indicated for clients who have thrombocytopenia, which is a low number of platelets that impairs blood clotting. However, this is not the case for a client with neutropenia, which affects the white blood cells that fight infections.

Choice C reason: This is incorrect because assessing vital signs every 4 hours is not the most important intervention for the nurse to implement. Vital signs are important indicators of the client's health status and may reveal signs of infection, such as fever, tachycardia, or hypotension. However, this is not a sufficient measure to prevent or treat infections in a client with neutropenia, who needs more aggressive and proactive interventions.

Choice D reason: This is correct because placing the client in protective isolation is the most important intervention for the nurse to implement. Protective isolation, also known as reverse isolation or neutropenic precautions, is a set of measures that aim to protect the client from exposure to pathogens that may cause infections. These include wearing gloves, masks, gowns, and eye protection; using sterile equipment and techniques; avoiding contact with people who are sick or have infections; and restricting visitors and fresh flowers or fruits.

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Correct Answer is ["F","H"]

Explanation

a) Basic metabolic panel: This is a blood test that measures the levels of electrolytes, glucose, calcium, and kidney function. It is not a priority order for this client because her glucose level is within the normal range and her symptoms are not indicative of electrolyte imbalance or kidney failure.

b) Echocardiogram: This is a test that uses sound waves to create images of the heart and its valves, chambers, and blood flow. It is not a priority order for this client because her chest discomfort may not be related to a cardiac problem and her SpO2 is normal, indicating adequate oxygenation.

c) CT scan of abdomen: This is a test that uses X-rays to create detailed pictures of the organs and structures in the abdomen. It is not a priority order for this client because her abdominal pain is not severe or acute and her nausea and poor appetite may be due to her illness or dialysis.

d) Blood cultures times 2 sets: This is a test that checks for the presence of bacteria or fungi in the blood. It is not a priority order for this client because she does not have signs of infection such as fever, chills, or leukocytosis.

e) Chest X-ray: This is a test that uses X-rays to create images of the lungs and chest wall. It is not a priority order for this client because she does not have respiratory symptoms such as cough, shortness of breath, or wheezes.

f) Place on continuous cardiac monitor: This is an order that requires the nurse to attach electrodes to the client's chest and monitor the heart rate and rhythm continuously. This is a priority order for this client because she has a history of CAD and HTN and reports chest discomfort and lightheadedness, which could indicate a possible myocardial infarction (heart attack) or arrhythmia (irregular heartbeat).

g) CBC: This is a blood test that measures the number and types of blood cells, such as red blood cells, white blood cells, and platelets. It is not a priority order for this client because she does not have signs of anemia, bleeding, or infection.

h) 12 lead EKG: This is a test that records the electrical activity of the heart from 12 different angles. It can detect abnormalities in the heart's rhythm, conduction, or damage. This is a priority order for this client because she has a history of CAD and HTN and reports chest discomfort and lightheadedness, which could indicate a possible myocardial infarction (heart attack) or arrhythmia (irregular heartbeat).

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

Correct Answer is B

Explanation

Choice A reason: Using incentive spirometer is not an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it is not related to the procedure or the condition. The incentive spirometer is a device that helps improve lung function and prevent respiratory complications by encouraging deep breathing and coughing. Therefore, this choice is incorrect.

Choice B reason: Monitoring urinary stream for decrease in output is an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it can indicate urinary retention or obstruction, which are potential complications of the procedure. The client should report any difficulty or inability to urinate, severe pain, or fever to the health care provider. Therefore, this choice is correct.

Choice C reason: Reporting when hematuria becomes pink tinged is not an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it is not a sign of a problem. Hematuria, or blood in the urine, is a common and expected finding after the procedure, and it usually resolves within a few days. The client should drink plenty of fluids to flush out the blood clots and debris. Therefore, this choice is incorrect.

Choice D reason: Restricting physical activities is an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, but it is not the best answer. The client should avoid strenuous activities, such as lifting heavy objects, driving, or sexual intercourse, for at least two weeks after the procedure to prevent bleeding and infection. However, this information is less important than monitoring urinary stream for decrease in output. Therefore, this choice is not the best answer.

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A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10⁹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2500 to 5800/mm³ (2.5 to 5.8 x 10⁹/L)]

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse is reviewing the physician orders. Which of the following physician’s orders requires priority attention from the nurse? Select all that apply.

Correct Answer is ["F","H"]

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 B

Explanation

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)

A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10⁹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2500 to 5800/mm³ (2.5 to 5.8 x 10⁹/L)]

Exhibits Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response.

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?

A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10⁹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
Reference Range:
Neutrophils (ANC) [2500 to 5800/mm³ (2.5 to 5.8 x 10⁹/L)]