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 ["1.5"]
Explanation
To administer the correct dose of desipramine, which is 150 mg, when the available tablet strength is 100 mg, the nurse would need to give 1.5 tablets.
Correct Answer is B
Explanation
A. PSA levels themselves do not indicate a gene mutation. Elevated PSA levels are primarily associated with prostate conditions rather than genetic mutations. While certain genetic mutations can predispose individuals to prostate cancer, PSA alone does not diagnose genetic mutations.
B. Elevated PSA levels can indicate the possibility of prostate cancer, but further testing is necessary to confirm the diagnosis. Additional tests may include a digital rectal exam (DRE), imaging studies (such as ultrasound or MRI), and a prostate biopsy.
C. Elevated PSA levels can suggest prostate cancer, but they do not definitively diagnose it. Prostate cancer can only be confirmed through a biopsy that identifies cancerous cells in the prostate tissue.
D. BPH is a non-cancerous enlargement of the prostate gland that commonly occurs in older men. While BPH can cause urinary symptoms similar to prostate cancer, elevated PSA levels are not typically associated with BPH alone. PSA elevation is more specific to prostate cancer but can also occur with other prostate conditions.
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