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 C

Explanation

A. An HbA1c level of 7.5% indicates suboptimal long-term glucose control. The target for many diabetic patients is usually below 7%, but it may not require immediate action compared to more acute indicators.
B. A 2-hour post-prandial blood glucose level of 122 mg/dL is slightly above the normal range but not significantly high. This result alone is not as indicative of inadequate control as other values.
C. A random blood glucose level of 300 mg/dL is significantly elevated and indicates poor glucose control. This value is much higher than the normal range and suggests a need for further teaching and adjustment of diabetes management.
D. A fasting blood glucose level of 48 mg/dL is low and could indicate hypoglycemia rather than inadequate control. This level requires immediate attention but does not reflect poor long-term diabetes management.

A. Current anticoagulant use B. Blood pressure of 160/85 mm Hg C. Complete neurologic assessment D. Current treatment for client's peptic ulcer disease

Correct Answer is A

Explanation

A. Assessing current anticoagulant use is a priority because t-PA (tissue plasminogen activator) can increase the risk of bleeding, especially if the client has been on anticoagulant medications. It is crucial to determine if there are any contraindications or increased risks for bleeding.
B. While blood pressure control is important, it is secondary to understanding the client's anticoagulant use as it directly affects the safety of t-PA administration.
C. A complete neurologic assessment is important but comes after ensuring there are no contraindications such as recent anticoagulant use that could affect the safety of t-PA.
D. Current treatment for peptic ulcer disease may be relevant for bleeding risks but is not as immediately critical as reviewing anticoagulant use for t-PA safety.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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