A nurse is caring for a client who is receiving cisplatin for 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
Hct
Platelets
Albumin
12.1 g/dL
36.5%
170,000/mm3
5 g/dL
The client has an increased risk of infection.
The client should receive a diet with increased protein.
The client has an increased risk for bleeding.
The client should receive an erythropoiesis stimulating agent.
Correct Answer : A,C
Answer: A. The client has an increased risk of infection.
Rationale: This is because the client's white blood cell (WBC) count is low, which indicates a compromised immune system. The normal range for WBC is 4,000 to 11,000/mm3. A low WBC count can be caused by chemotherapy, which is a common treatment for ovarian cancer. The nurse should monitor the client for signs of infection, such as fever, chills, redness, swelling, or drainage, and implement infection prevention measures, such as hand hygiene, sterile technique, and isolation precautions.
Answer: C. The client has an increased risk for bleeding.
Rationale: This is because the client's platelet count is low, which indicates a reduced ability to form clots and stop bleeding. The normal range for platelets is 150,000 to 400,000/mm3. A low platelet count can be caused by chemotherapy, which can damage the bone marrow where platelets are produced. The nurse should monitor the client for signs of bleeding, such as petechiae, ecchymosis, hematuria, or melena, and implement bleeding prevention measures, such as avoiding invasive procedures, applying pressure to puncture sites, and using soft-bristled toothbrushes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiceD. Fresh flowers and potted plants in the room.
Choice A rationale:
While activities that could result in bleeding should be avoided in patients with low platelet counts, this is not directly related to neutropenia.Neutropenia primarily increases the risk of infection rather than bleeding.
Choice B rationale:
Restricting oral fluid intake to between meals is not relevant to managing neutropenia.Adequate hydration is important, but the timing of fluid intake does not impact neutropenia management.
Choice C rationale:
While limiting visitors can help reduce the risk of infection, it is not necessary to restrict all visitors.Instead, visitors should follow strict hygiene practices, such as handwashing and wearing masks, to minimize infection risk.
Choice D rationale:
Fresh flowers and potted plants can harbor bacteria and fungi, which pose a significant infection risk to neutropenic patients.Therefore, these should be avoided in the patient’s room.
Correct Answer is A
Explanation
This is because tuberculosis can affect the liver and cause hepatotoxicity, especially if the client is taking anti-tuberculosis medications. The nurse should monitor the client's liver function tests, such as AST and ALT levels, and observe for signs of liver damage, such as yellow sclera, dark urine, clay-colored stools, and abdominal pain.
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