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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Obtaining a soft diet for the client is not the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. A soft diet can help reduce the irritation and discomfort of the oral mucosa, but it does not address the underlying cause of the inflammation and infection. The nurse should first assess the client's oral hygiene and provide appropriate interventions to prevent further complications.
Choice B reason: Encouraging frequent mouth care is the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Frequent mouth care can help prevent or reduce the severity of mucositis by removing plaque, bacteria, and debris from the oral cavity, and by moisturizing and soothing the oral tissues. The nurse should instruct the client to use a soft toothbrush, a mild toothpaste, and a saline or bicarbonate rinse at least four times a day, and to avoid alcohol, tobacco, spicy, acidic, or hot foods and beverages.
Choice C reason: Cleansing the tongue and mouth with swabs is not the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Swabs can be abrasive and damaging to the oral mucosa, especially if they are dry or contain alcohol or hydrogen peroxide. Swabs can also increase the risk of bleeding, infection, and ulceration of the oral tissues. The nurse should use a soft toothbrush or a gentle sponge to clean the tongue and mouth.
Choice D reason: Administering a topical analgesic per protocol is not the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. A topical analgesic can provide temporary relief of pain and discomfort, but it does not address the underlying cause of the inflammation and infection. The nurse should first assess the client's oral hygiene and provide appropriate interventions to prevent further complications. The nurse should also monitor the client's response to the analgesic and report any adverse effects or inadequate pain control.
Correct Answer is D
Explanation
Choice A reason: Fasting blood sugar of 200 mg/dL (11.1 mmol/L) indicates hyperglycemia, which is a high level of glucose in the blood. It can be caused by diabetes mellitus, stress, infection, or medication. Hyperglycemia can cause symptoms such as thirst, hunger, frequent urination, fatigue, and blurred vision. However, it does not affect the safety or accuracy of MRI with contrast.
Choice B reason: Glycosylated hemoglobin A1c of 8% indicates poor glycemic control over the past three months. It can be caused by diabetes mellitus, chronic kidney disease, or hemoglobinopathy. Glycosylated hemoglobin A1c reflects the average blood glucose level over the lifespan of red blood cells, which is about 120 days. However, it does not affect the safety or accuracy of MRI with contrast.
Choice C reason: Blood urea nitrogen of 22 mg/dL (7.9 mmol/L) indicates mild azotemia, which is a high level of nitrogenous waste products in the blood. It can be caused by dehydration, high protein intake, gastrointestinal bleeding, or kidney impairment. Azotemia can cause symptoms such as nausea, vomiting, confusion, and lethargy. However, it does not affect the safety or accuracy of MRI with contrast.
Choice D reason: Serum creatinine of 1.9 mg/dL (169 umol/L) indicates moderate renal insufficiency, which is a reduced ability of the kidneys to filter and excrete waste products and fluids from the body. It can be caused by diabetes mellitus, hypertension, glomerulonephritis, or nephrotoxic drugs. Renal insufficiency can cause symptoms such as edema, anemia, electrolyte imbalance, and acidosis. It can also increase the risk of contrast-induced nephropathy, which is a sudden deterioration of kidney function after exposure to contrast media used for imaging studies such as MRI. Contrast-induced nephropathy can lead to acute kidney injury, dialysis requirement, or even death. Therefore, serum creatinine should be reported to the healthcare provider before MRI with contrast to assess the risk and benefit of the procedure and to take preventive measures such as hydration, medication adjustment, or alternative imaging modalities.
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