A client with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, and the client is experiencing fatigue and mild nausea. Which nursing action is the highest priority?

Assess for sources of bleeding and provide pressure on wounds

Limit contact with infected visitors and place in positive pressure isolation

Administer antiemetics and assess nutrition and hydration status

Monitor energy levels and begin energy-conserving techniques

Answer and Explanation

The Correct Answer is B

A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.

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Correct Answer is D

Explanation

A. Absence of pulmonary and peripheral edema is not a primary goal of vasopressor therapy. The focus is on improving blood pressure and perfusion.
B. Vasopressor therapy aims to increase blood pressure, not reduce stroke volume or cardiac output.
C. Vasopressors are used to increase blood pressure, so reducing blood pressure is not an intended goal.
D. The primary goal of vasopressor therapy in septic shock is to maintain an adequate mean arterial pressure (MAP) to ensure adequate organ perfusion and prevent organ failure.

A. The client should avoid crowded places. B. The client should avoid eating fresh fruits and vegetables. C. The client should maintain at least 6 feet from any visitors. D. The client should avoid washing off the radiation tattoo markings.

Correct Answer is C

Explanation

A. Avoiding crowded places is a precaution related to general health and infection control but is not specifically linked to internal radiation therapy.
B. Avoiding fresh fruits and vegetables is not required for internal radiation therapy. Dietary restrictions are not typically necessary unless specified by the healthcare provider.
C. For internal radiation therapy, maintaining distance from others, typically around 6 feet, is important to minimize radiation exposure to others. This safety measure helps reduce the risk of radiation exposure to family members and visitors.
D. Radiation tattoo markings are used to ensure proper placement of the radiation source and should not be washed off. However, this precaution does not directly relate to safety around radiation exposure.

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A client with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, and the client is experiencing fatigue and mild nausea. Which nursing action is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The critical care nurse is preparing to initiate an infusion of a vasopressor medication to a client in septic shock. What goal of this treatment should the nurse identify?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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