A nurse is caring for a client who is receiving chemotherapy. The client's most recent lab results show a white blood cell count of 3,100/mm3, and a platelet count of 280,000/mm3. Based on these lab results, which nursing action is appropriate for this client?

Provide the client with an electric shaver for grooming.

Move the client to a negative pressure isolation room.

Encourage the client to select cooked vegetables rather than a salad for their lunch tray.

Educate the client to dab their nose, rather than forcefully blow their nose.

Answer and Explanation

The Correct Answer is A

A.   This option is appropriate because the client's low white blood cell count (3,100/mm³) suggests they are at risk for infection due to chemotherapy-induced immunosuppression. Using an electric shaver reduces the risk of cuts and nicks that could potentially lead to infections.

B.   This option is not necessary based on the client's current lab results. Negative pressure isolation rooms are typically reserved for clients with severely compromised immune systems, such as those with very low neutrophil counts (neutropenia). A white blood cell count of 3,100/mm³ is within a range where standard precautions are usually sufficient.
C.   This option addresses food safety precautions for clients with neutropenia (low white blood cell count). Raw vegetables, including salads, have a higher risk of harboring bacteria that could cause infections. Therefore, cooked vegetables are safer for clients with compromised immune systems.
D.   This option is appropriate because chemotherapy-induced thrombocytopenia (low platelet count of 280,000/mm³) increases the risk of bleeding. Forceful blowing of the nose can traumatize the nasal mucosa and increase the risk of nosebleeds. Dabbing the nose gently is a safer method to avoid nosebleeds.

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Correct Answer is C

Explanation

A. This statement refers to medications like statins (e.g., rosuvastatin, atorvastatin) which are used to lower cholesterol levels and reduce the risk of atherosclerosis progression. Docusate sodium does not treat hyperlipidemia or affect plaque formation directly.
B. This refers to anticoagulant medications (e.g., heparin, warfarin, direct oral anticoagulants) which are used to prevent clot formation and reduce the risk of thromboembolic events such as stroke. Docusate sodium does not have anticoagulant properties.
C. After a myocardial infarction (MI), especially in the early recovery phase, vagal stimulation can exacerbate bradycardia or contribute to dysrhythmias. Stool softeners like docusate sodium help prevent constipation, which can stimulate the vagus nerve during straining, potentially leading to vagally mediated dysrhythmias such as bradycardia or atrioventricular blocks.
D. Diuretics (e.g., furosemide, hydrochlorothiazide) are used to reduce fluid retention and lower blood pressure by increasing urine output. Docusate sodium does not remove excess sodium or affect blood pressure regulation.

A. If you experience a headache after taking this medication, discontinue its use and seek medical attention. B. If the first tablet does not relieve your chest pain, you may take a second tablet 10 minutes later. C. Stand up slowly after taking this medication. D. Replace this medication every 3 months.

Correct Answer is B

Explanation

A. Headache is a common side effect of nitroglycerin due to its vasodilatory effects, especially in the head. Most headaches associated with nitroglycerin are mild and transient. Patients are generally advised to continue using the medication as prescribed unless the headache is severe or persistent.
B. Nitroglycerin tablets are used for the immediate relief of angina symptoms. If the first tablet does not adequately relieve chest pain within 5 minutes, the patient can take a second tablet. If the pain persists after the second tablet, emergency medical attention should be sought. However, it's important to note that the maximum number of tablets that can be taken within a short period should be specified by the healthcare provider, typically 2 or 3 tablets in 15 to 30 minutes.
C. Nitroglycerin can cause orthostatic hypotension, which is a drop in blood pressure upon standing up. This can lead to dizziness or fainting. Therefore, patients should be advised to stand up slowly after taking nitroglycerin to minimize the risk of falls or injury.
D. Nitroglycerin tablets are sensitive to light, heat, and moisture, which can reduce their effectiveness over time. Therefore, it's recommended to replace nitroglycerin tablets every 3 to 6 months to ensure potency and effectiveness.

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A nurse is caring for a client who is receiving chemotherapy. The client's most recent lab results show a white blood cell count of 3,100/mm3, and a platelet count of 280,000/mm3. Based on these lab results, which nursing action is appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing the use of docusate sodium (Colace) with a client who is recovering from a non-ST elevation myocardial infarction (NSTEMI). What is the rationale for administering this medication during the recovery from a myocardial infarction?

Correct Answer is C

Explanation

A client has been diagnosed with chronic stable angina and has a new prescription for nitroglycerin tablets. Which statement about this medication should the nurse include in the patient education?

Correct Answer is B

Explanation

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