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 C
Explanation
A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.
Correct Answer is D
Explanation
A. Decreased cardiac output is not a primary concern with chlorine exposure, which primarily affects the respiratory system.
B. Hypovolemia is not directly related to chlorine gas exposure. The primary concern is respiratory damage.
C. Chronic pain is not an immediate or primary finding in chlorine gas exposure; the focus is on acute respiratory effects.
D. Pulmonary edema is a common and severe consequence of chlorine gas inhalation due to the corrosive effect of chlorine on the respiratory tract, leading to fluid accumulation in the lungs.
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