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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}
Explanation
Placing the client on droplet precautions is anticipated as it is a standard practice to prevent infection, especially in immunocompromised patients like those undergoing chemotherapy.
A private room is also anticipated to reduce the risk of infection and provide a controlled environment for the patient's comfort and monitoring.
The insertion of an indwelling urinary catheter may be nonessential unless there is a specific indication, such as urinary retention or close monitoring of output in a critically ill patient, as it can increase the risk of urinary tract infections.
Checking the client's rectal temperature once daily could be contraindicated due to the risk of causing trauma or bleeding, especially considering the client's decreased platelet count, which could lead to increased bleeding risk.
Lastly, rinsing the client's mouth with 0.9% sodium chloride every 4 hours is anticipated to help manage the sore mouth, a common side effect of chemotherapy, and to maintain oral hygiene, which is crucial in preventing infections in immunocompromised patients.
Correct Answer is A
Explanation
A. Levothyroxine is used to replace thyroid hormone in hypothyroidism. Symptoms like tremors, nervousness, and insomnia can indicate that the dose is too high, suggesting possible hyperthyroidism.
B. Weight loss alone is not a primary indicator for adjusting levothyroxine. It is more important to monitor for symptoms of overdosage, such as those described in option A.
C. Levothyroxine does not increase the risk of bleeding. Monitoring is typically focused on thyroid hormone levels rather than bleeding risks.
D. Levothyroxine increases thyroid hormone levels, not decreases them. It is used to supplement the deficient hormone in hypothyroidism.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.