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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This option describes a phenomenon seen in heparin-induced thrombocytopenia (HIT), not in immune thrombocytopenic purpura (ITP). In HIT, antibodies against the PF4-heparin complex can cause platelet activation and aggregation, leading to thrombocytopenia. However, this is not characteristic of ITP.
B. Abnormally long von Willebrand factor is seen in von Willebrand disease (VWD), not in ITP. VWD is a bleeding disorder caused by deficiency or dysfunction of von Willebrand factor, which plays a key role in platelet adhesion and aggregation. It is not typically associated with ITP.
C. ADAMTS13 deficiency is characteristic of thrombotic thrombocytopenic purpura (TTP), not ITP. TTP is a rare blood disorder where small blood clots form in blood vessels throughout the body, leading to thrombocytopenia (low platelet count) and other complications. It is distinct from ITP.
D. In immune thrombocytopenic purpura (ITP), the immune system mistakenly attacks and destroys platelets, leading to a low platelet count. Antibodies, particularly anti-platelet antibodies such as anti-GP IIb/IIIa or anti-GP Ib/IX, coat the surface of platelets. These antibody-coated platelets are recognized and destroyed by macrophages in the spleen and liver, contributing to thrombocytopenia.
Correct Answer is B
Explanation
A. Splenectomy is not a standard treatment for myasthenia gravis. The spleen's role is primarily related to immune function and blood filtration rather than the pathophysiology of MG.
B. Thymectomy is a surgical procedure that involves the removal of the thymus gland. The thymus gland plays a role in the development and regulation of the immune system. In some cases of myasthenia gravis, especially in younger patients or those with thymoma (a tumor of the thymus gland), thymectomy can lead to improvement or remission of symptoms. This procedure is considered in cases where myasthenia gravis is refractory to medication or in cases associated with thymoma.
C. Appendectomy is the surgical removal of the appendix and is not a treatment for myasthenia gravis. The appendix is not implicated in the pathophysiology of MG.
D. Cholecystectomy is the surgical removal of the gallbladder and is performed for conditions related to the gallbladder, such as gallstones or inflammation. It is not indicated for the treatment of myasthenia gravis.
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