A nurse is caring for a client
A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up? Select all that apply.
Temperature
Potassium level
WBC count
Blood pressure
Breath sounds
Correct Answer : A,C,E
A. Temperature (38.6°C / 101.5°F): A fever in a chemotherapy client with a low WBC count is concerning for infection or neutropenic fever, which can be life-threatening. Neutropenia (WBC 3,800/mm³) weakens the immune response, making infections more severe.
B. Potassium level (3.6 mEq/L): The potassium level is within normal limits (3.5–5.0 mEq/L) and does not indicate an immediate concern.
C. WBC count (3,800/mm³): The client's WBC count has dropped significantly from 8,000/mm³ to 3,800/mm³, indicating chemotherapy-induced neutropenia. A low WBC count increases the risk of infection and warrants further assessment and precautions.
D. Blood pressure (114/56 mmHg): The blood pressure is within an acceptable range and does not indicate hypotension or other hemodynamic instability.
E. Breath sounds (Crackles at lung bases): New crackles at the lung bases suggest a potential respiratory infection (e.g., pneumonia), which is especially concerning in neutropenic clients. The presence of fever and tachypnea (respiratory rate 24/min) further supports possible infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Drooling is associated with epiglottitis, not bacterial pneumonia.
B. Malaise (fatigue and weakness) is a common systemic symptom of bacterial pneumonia due to infection and fever.
C. Tinnitus (ringing in the ears) is not a symptom of bacterial pneumonia; it is often linked to ear infections or medication side effects.
D. Rhinorrhea (runny nose) is more common with viral infections like the common cold rather than bacterial pneumonia.
Correct Answer is B
Explanation
A. Incorrect – Oliguria (decreased urine output), not polyuria, is expected due to kidney inflammation.
B. Correct – Hematuria (blood in urine) is a hallmark sign due to glomerular damage. Urine may appear tea- or cola-colored.
C. Incorrect – Weight gain is expected due to fluid retention, not weight loss.
D. Incorrect – Hypertension (not hypotension) occurs due to fluid overload and sodium retention.
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