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 ["A","C","E"]
Explanation
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.
Correct Answer is C
Explanation
A. Incorrect – Preoccupation with aging is more characteristic of obsessive-compulsive personality disorder (OCPD) or body dysmorphic disorder.
B. Incorrect – Ritualistic behavior is a hallmark of obsessive-compulsive disorder (OCD), not narcissism.
C. Correct – Clients with narcissistic personality disorder often have difficulty trusting others, believe they are superior, and may exhibit arrogance and entitlement.
D. Incorrect – Separation anxiety is seen in dependent personality disorder, not narcissistic personality disorder.
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