A nurse receives a report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?
Notify the primary health care provider and request antibiotics.
Inform the client that this signifies inflammation.
Document findings and continue monitoring.
Place the client in protective isolation.
The Correct Answer is A
Rationale for Choice A:
A shift to the left in the white blood cell (WBC) count indicates an increased presence of immature neutrophils, known as bands. This is a hallmark sign of infection, as the body is rapidly producing and releasing these cells to fight off invading pathogens.
Prompt notification of the primary health care provider is crucial to initiate timely antibiotic therapy, if indicated. Early intervention with appropriate antibiotics can effectively combat the infection, prevent its progression, and potentially avert serious complications.
Delaying antibiotic treatment can allow the infection to worsen, potentially leading to sepsis, septic shock, or other life- threatening conditions.
Rationale for Choice B:
While informing the client about the significance of a shift to the left is important for education and understanding, it does not address the immediate need for medical intervention.
The priority action is to involve the primary health care provider for prompt assessment and potential initiation of antibiotic therapy.
Rationale for Choice C:
Documenting findings and continuing to monitor the client's condition is essential for ongoing assessment and evaluation, but it does not constitute a proactive intervention to address the underlying infection.
Documentation alone does not initiate treatment, and monitoring without intervention risks allowing the infection to progress.
Rationale for Choice D:
Protective isolation is not routinely indicated for clients with a shift to the left in their WBC count unless there is a specific concern for transmission of a highly contagious infection.
The decision to implement protective isolation measures would be based on the client's overall clinical presentation and potential infectious risks, as determined by the primary health care provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Wearing a respirator when handling urine output is not routinely recommended for MRSA infections. While airborne transmission of MRSA is possible, it is primarily spread through direct contact with infected skin or surfaces. Respirators are typically reserved for situations where there is a high risk of aerosolization, such as during certain medical procedures.
The use of a respirator can be cumbersome and uncomfortable, and it may not provide significant additional protection in this context.
It's important to prioritize hand hygiene and contact precautions over respirator use for routine care of patients with MRSA infections.
Choice B rationale:
Limiting visitors strictly to immediate family members only is not necessary for MRSA infection control. Visitors can be educated on proper hand hygiene and contact precautions to minimize the risk of transmission.
Restricting visitors can have negative psychosocial impacts on the patient, such as isolation and decreased social support. It's important to balance infection control measures with the patient's overall well-being.
Choice C rationale:
Washing hands only after removing gloves post-care is inadequate for MRSA infection control. Hands should be washed thoroughly with soap and water or an alcohol-based hand sanitizer:
Before and after entering the patient's room
Before and after any contact with the patient or their surroundings After removing gloves
After using the toilet Before eating or drinking.
Choice D rationale:
Vancomycin is an antibiotic that is effective against MRSA infections. It is often the first-line treatment for these infections.
Preparing to administer vancomycin as prescribed by the healthcare provider is the most appropriate action to take to address the patient's MRSA infection.
Prompt initiation of appropriate antibiotic therapy is essential to controlling the infection and preventing complications.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Massaging the site with scented oils is not recommended as it may further irritate the inflamed tissue. Additionally, scented oils can cause allergic reactions or skin irritation, worsening the client's discomfort.
Choice B rationale: Applying warm compresses to the site increases blood flow, reduces inflammation, and provides pain relief. Warm compresses also promote healing by improving circulation and reducing edema, making them an appropriate intervention for phlebitis.
Choice C rationale: Administering topical lidocaine to the site is generally not recommended without a prescription. Although it may provide localized pain relief, it can mask underlying issues and delay appropriate medical assessment and treatment.
Choice D rationale: Administering prescribed oral pain medication can provide systemic pain relief. However, it may not be as effective as a localized treatment for reducing inflammation and discomfort at the site of the peripheral vascular access device.
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