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 B
Explanation
A. Drying the sclera with a cotton swab prior to administering eye drops is not recommended and could introduce fibers or cause irritation. Proper eye drop administration does not require drying the sclera.
B. Administering the medications 5 minutes apart is correct because it allows each medication to be absorbed properly, preventing the second drop from washing out the first. This timing helps ensure that both medications are effective.
C. Touching the tip of the dropper to the sclera is incorrect and can introduce contaminants, leading to infection. Eye drops should be administered without the dropper touching the eye to maintain sterility.
D. Holding pressure on the conjunctival sac for 2 minutes is excessive. The recommended practice is to gently press on the nasolacrimal duct for 1-2 minutes after administration to prevent systemic absorption, especially with medications like timolol.
Correct Answer is A
Explanation
A. Difficulty swallowing in a client with facial burns can indicate airway compromise due to edema and should be reported immediately as it may require urgent intervention to secure the airway.
B. While pain is a significant concern and should be managed, it is not as immediately life-threatening as potential airway obstruction.
C. A respiratory rate of 24 breaths per minute is elevated but within the range of mild tachypnea, which could be due to pain or anxiety, and is not the most urgent finding.
D. Urinary output of 25 mL/hr is below normal and indicates possible hypovolemia or kidney injury, but airway concerns take precedence in this scenario.
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