A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?
WBC 1500/mm3
RBC 5 million/mm3
Platelets 155,000/mm3
Hemoglobin 12 g/dL
The Correct Answer is A
A. A WBC count of 1500/mm3 is significantly low (normal range is 4500-11000/mm3) and indicates neutropenia, placing the client at high risk for infection. This finding should be reported to the provider immediately.
B. An RBC count of 5 million/mm3 is within the normal range for females (4.2-5.4 million/mm3) and does not indicate an immediate concern in the context of chemotherapy.
C. Platelet count of 155,000/mm3 is on the lower end of the normal range (150,000-450,000/mm3) but does not pose an immediate risk compared to neutropenia.
D. A hemoglobin level of 12 g/dL is within the normal range for females (12-16 g/dL) and does not require urgent reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Applying petroleum jelly to the client's lips can lead to aspiration if the client is unable to swallow properly. It is not recommended as a routine practice for oral care.
B. A stiff toothbrush can cause gum damage or discomfort. A soft toothbrush is preferred for oral care, especially for clients who may have sensitive or fragile gums.
C. Using the thumb and index finger to keep the client's mouth open is not safe or effective. It can cause discomfort or injury. Using appropriate tools, like a mouth prop or suction if necessary, is recommended.
D. Turning the client on their side before starting oral care is the correct action. This position helps prevent aspiration of secretions or water during oral care, reducing the risk of choking or aspiration pneumonia.
Correct Answer is D
Explanation
A. Suctioning the nostril is not appropriate as it could exacerbate potential cerebrospinal fluid (CSF) leakage or cause further injury.
B. Asking the client to blow their nose could increase intracranial pressure and potentially worsen a skull fracture or CSF leak.
C. While notifying the physician is important, the initial step should be to determine whether the clear drainage is CSF, which has specific implications.
D. Testing the drainage for glucose is crucial because a positive glucose test indicates that the fluid is likely CSF, which can signal a skull fracture and possible brain injury. This finding requires immediate medical evaluation to manage potential complications like infections or worsening of the fracture.
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