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 B

Explanation

A. Whole milk contains saturated fats, which can contribute to overall cardiovascular health risks. However, it's not directly linked to causing PACs. While reducing saturated fat intake is generally beneficial for heart health, whole milk alone might not significantly exacerbate PACs compared to other dietary factors.

B. Black tea contains caffeine, which is a stimulant that can potentially increase heart rate and trigger PACs or other irregular heart rhythms in sensitive individuals. Therefore, black tea is a consideration for clients with PACs as it can be a potential trigger.
C. Bacon is high in saturated fat and sodium, which can contribute to cardiovascular risks and overall heart health concerns. High-fat foods like bacon can indirectly influence heart rhythms, but there's not a direct correlation between consuming bacon and PACs.
D. Eggs and cheese are high in saturated fats and cholesterol, which can impact cardiovascular health. While not directly linked to causing PACs, the high-fat content of scrambled eggs with cheese may contribute to overall heart health concerns.

A. "I feel short of breath when I lie down flat." B. "The sputum I have been coughing up is pink." C. "The nurse I had yesterday said she could hear fluid in my lungs." D. "I feel like fluid has been building up in my abdominal area."

Correct Answer is D

Explanation

A. This symptom is consistent with orthopnea, which is common in left-sided heart failure rather than right-sided heart failure. In orthopnea, patients experience shortness of breath when lying flat because fluid accumulates in the lungs due to impaired left ventricular function.
B. Pink-tinged or blood-tinged sputum, known as hemoptysis, can occur in left-sided heart failure due to pulmonary congestion and elevated pressures in the pulmonary circulation. This symptom is not typically associated with right-sided heart failure.
C. This finding suggests pulmonary congestion, which is more indicative of left-sided heart failure. In left- sided heart failure, fluid backs up into the lungs, leading to crackles or rales on auscultation.
D. This statement is consistent with right-sided heart failure. In right-sided heart failure, the right ventricle fails to effectively pump blood into the pulmonary circulation, causing fluid to back up into the venous system. This can lead to peripheral edema (such as in the legs and abdomen) and abdominal distension due to ascites (fluid accumulation in the peritoneal cavity).

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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 caring for a 24-year-old client who has frequent premature atrial contractions seen on the cardiac monitor. The nurse understands that the client requires additional education when the client selects which of the following items for the breakfast tray?

Correct Answer is B

Explanation

The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?

Correct Answer is D

Explanation

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