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. Acetaminophen is used to treat fever (pyrexia), but in hyperthermia, external cooling measures are more effective.
B. Hyperthermia can cause neurological complications, including seizures, so precautions such as padded side rails should be in place.
C. Ice water immersion can cause vasoconstriction and shivering, worsening hyperthermia.
D. A thermal blanket generates heat and is contraindicated in hyperthermia.
Correct Answer is D
Explanation
A. A client with a sealed radiation implant requires strict precautions and monitoring, making them unsuitable for early discharge.
B. A client with COPD and a respiratory rate of 44/min is unstable and requires close monitoring.
C. A client on heparin for deep vein thrombosis (DVT) requires continued monitoring due to the risk of embolism.
D. A client 1 day postoperative after a vertebroplasty is typically stable and may be discharged with instructions for at-home care.
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