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 B

Explanation

A. The time of the burn helps in understanding how long the client has been exposed and may influence the assessment of burn progression, but it does not directly determine the severity.
B. The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.
C. The cause of the burn is important for treatment considerations and understanding the mechanism of injury but does not impact the assessment of burn severity.
D. The location of the burn affects the potential for complications and functional impairment but is secondary to the depth in determining overall burn severity.

A. Petechiae B. Decreased white blood cell count C. Increased fatigue D. Unexplained bone pain

Correct Answer is A

Explanation

A. Petechiae are small, red or purple spots on the skin that indicate bleeding under the skin and are a classic sign of thrombocytopenia, a condition characterized by a low platelet count.
B. A decreased white blood cell count is more indicative of leukopenia, not thrombocytopenia. Thrombocytopenia specifically affects platelet counts.
C. Increased fatigue can be a symptom of many conditions but is not specific to thrombocytopenia. It may occur due to anemia or other side effects of chemotherapy.
D. Unexplained bone pain is not a typical symptom of thrombocytopenia. It might be related to other conditions or side effects but is not specific to low platelet counts.

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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

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Correct Answer is B

Explanation

A client on the oncology unit is receiving a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. For which symptom should the nurse assess in clients at risk for thrombocytopenia?

Correct Answer is A

Explanation

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