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 B
Explanation
A. Hypernatremia can indicate dehydration or other electrolyte imbalances. Furosemide can further affect electrolyte balance, especially sodium and potassium. However, this sodium level is only slightly elevated and may not necessarily require immediate action regarding furosemide administration.
B. Furosemide is a diuretic that can further decrease blood pressure due to its effects on fluid volume reduction. Administering it to a patient with already low blood pressure could potentially lead to significant hypotension and compromise perfusion to vital organs.
C. While incontinence itself may not directly contraindicate furosemide administration, it could indicate underlying issues such as bladder dysfunction or fluid overload that need further evaluation. This finding alone would not necessarily require holding the medication, but it warrants further assessment and consideration in the clinical context.
D. Normal serum potassium levels typically range from 3.5-5.0 mEq/L. A level of 5.3 mEq/L indicates hyperkalemia (elevated potassium). While this potassium level is mildly elevated, it would not be a reason on its own to hold furosemide. Monitoring potassium levels closely and potentially adjusting potassium
Correct Answer is C
Explanation
A. Defibrillation is not typically indicated for atrial fibrillation. Atrial fibrillation involves disorganized electrical activity in the atria rather than a shockable rhythm like ventricular fibrillation or ventricular tachycardia. Therefore, emergency defibrillation is not appropriate for a client with persistent atrial fibrillation.
B. CABG is a surgical procedure used to improve blood flow to the heart muscle by bypassing blocked coronary arteries. It is primarily indicated for clients with significant coronary artery disease that cannot be managed effectively with medications or less invasive
C. Anticoagulant therapy, such as with medications like warfarin or direct oral anticoagulants (DOACs), is crucial for clients with atrial fibrillation. AFib predisposes individuals to an increased risk of stroke due to the potential formation of blood clots in the atria. Anticoagulants help prevent clot formation and reduce the risk of stroke.
D. Diuretics are medications that increase urine output and are often used to manage fluid overload or congestion in conditions such as heart failure or volume overload. However, diuretic therapy alone does not address the underlying rhythm abnormality of atrial fibrillation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.