A nurse is caring for a client who is receiving cisplatin for the treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client?
- WBC: 1,400/mm³
- RBC: 4.3 x 10¹²/L
- Hgb: 12.1 g/dL
- Hct: 36.5%
- Platelets: 170,000/mm³
- Albumin: 4.5 g/dL
Given the options:
The client should receive an erythropoiesis-stimulating agent.
The client should receive a diet with increased protein.
The client has an increased risk of infection.
The client has an increased risk for bleeding.
The Correct Answer is C
Choice A reason: The use of erythropoiesis-stimulating agents (ESAs) is indicated for anemia due to chemotherapy¹. However, the client's hemoglobin (Hgb) level is 12.1 g/dL, which is within the normal range (normal: 12-15.5 g/dL for women). Therefore, administering an ESA is not indicated based on the Hgb level provided.
Choice B reason: A diet with increased protein can be beneficial for patients undergoing chemotherapy as it helps in tissue repair and immune system function. However, the client's albumin level is 4.5 g/dL, which falls within the normal range (normal: 3.4-5.4 g/dL), suggesting adequate protein intake. Thus, there is no indication that the client requires an increased protein diet based on the albumin level provided.
Choice C reason: The client's white blood cell (WBC) count is 1,400/mm³, which is below the normal range (normal: 4,500-11,000/mm³). This condition, known as leukopenia, significantly increases the risk of infection³. Therefore, the nurse should prioritize monitoring for signs of infection and implementing infection control measures.
Choice D reason: The client's platelet count is 170,000/mm³, which is within the normal range (normal: 150,000-450,000/mm³). Although cisplatin can cause thrombocytopenia, the current platelet count does not indicate an increased risk for bleeding⁴. Therefore, this choice is not correct based on the platelet count provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
The statement that the prosthesis will be adjustable depending on what shoe you are wearing is not accurate. Prostheses are custom-made to fit the individual and are not typically adjustable to different shoe types. The fit and alignment of the prosthesis are crucial for comfort and function, and these are not dependent on the footwear.
Choice B reason:
It is true that clients will need to do special exercises in advance of getting their prosthesis. These exercises are designed to strengthen the remaining limb and prepare the body for the use of a prosthesis. They are an essential part of rehabilitation and help ensure the best possible outcome for the client.
Choice C reason:
Clients are not fitted for their prosthesis at the time of surgery. Fitting for a prosthesis typically occurs after the residual limb has sufficiently healed, which can take several weeks. The fitting process involves careful measurement and customization to ensure the prosthesis will be comfortable and functional.
Choice D reason:
While a special dressing is applied postoperatively, its primary purpose is not to cushion the prosthesis. Initially, dressings are used to protect the surgical site, control swelling, and promote healing. The prosthesis is fitted after the residual limb has healed, and at that time, different types of socket liners may be used for cushioning.
Correct Answer is D
Explanation
Choice A reason:
While examining the client for areas of skin breakdown is an important part of ongoing care, especially for clients with spinal cord injuries who are at increased risk for pressure ulcers, it is not the first action to take when autonomic dysreflexia is suspected. Skin breakdown is not an immediate life-threatening issue compared to the potential complications of autonomic dysreflexia.
Choice B reason:
Checking the client's bladder for distention is a critical step in the management of autonomic dysreflexia, as an overfull bladder is a common trigger for this condition. However, the very first action should be to place the client in a sitting position to lower blood pressure, which can be dangerously high during an episode of autonomic dysreflexia.
Choice C reason:
Checking for fecal impaction is another important intervention for managing autonomic dysreflexia, as an impacted bowel can also trigger an episode. However, similar to checking for bladder distention, this is not the first action to take. Immediate measures to lower blood pressure are prioritized for the safety of the client.
Choice D reason:
Placing the client in a sitting position, or elevating the head of the bed to at least 45 degrees, is the first and most critical action when autonomic dysreflexia is suspected. This position helps to lower blood pressure by promoting venous return to the heart and can prevent complications such as stroke from the sudden hypertension associated with autonomic dysreflexia.
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.