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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Encourage the client to increase fluid intake: This is important to prevent dehydration, which can be a complication of influenza.
B. Wear a mask when caring for the client: Influenza is a highly contagious virus, and wearing a mask can help prevent the spread of infection.
C. Prepare to administer an antibiotic to the client: Antibiotics are not typically used to treat influenza, which is a viral infection. However, if a bacterial infection develops as a complication, antibiotics may be necessary.
D. Place the client in a private room: Isolating the client in a private room can help prevent the spread of influenza to other patients and healthcare workers.
E. Place the client on contact precautions: Influenza is primarily spread through respiratory droplets, so droplet precautions are appropriate. Contact precautions are not necessary for influenza.
Correct Answer is B
Explanation
B. Assessing the client's activated partial thromboplastin time (aPTT) is important to monitor the effectiveness of treatment and manage bleeding risk. Hemophilia A is characterized by a deficiency in clotting factor VIII, which prolongs the aPTT.
A. Applying heated compresses is not recommended for hemarthrosis; instead, cold compresses should be used to reduce bleeding and swelling.
C. Low-dose aspirin is contraindicated for clients with hemophilia because it can further inhibit platelet function and increase bleeding risk.
D. Autologous blood transfusion is not typically required for hemophilia; factor replacement therapy is the standard treatment.
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