A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which of the following interventions?
Monitoring the patient's breathing and reviewing the patients arterial blood gases
Monitoring the patient's temperature and reviewing the patient's complete blood count with differential
Monitoring the patients blood pressure and reviewing the patient's hematocrit
Monitoring the patient's heart rate and reviewing the patient's hemoglobin
The Correct Answer is B
A. Monitoring the patient's breathing and reviewing the patient's arterial blood gases:
Rationale: While respiratory status is crucial in any patient assessment, arterial blood gases primarily evaluate respiratory function. Neutropenia directly affects the immune system, not respiratory function.
Appropriateness: Not directly related to assessing neutropenia.
B. Monitoring the patient's temperature and reviewing the patient's complete blood count with differential:
Rationale: Neutropenia can cause fever due to the increased risk of infection. Monitoring temperature and reviewing the complete blood count (CBC) with differential, specifically the neutrophil count, is essential in evaluating neutropenia and identifying potential infections.
Appropriateness: Correct. Monitoring temperature and reviewing CBC with differential are crucial in assessing neutropenia.
C. Monitoring the patient's blood pressure and reviewing the patient's hematocrit:
Rationale: Blood pressure assessment and hematocrit evaluation are essential aspects of general patient care but are not specific to neutropenia.
Appropriateness: Not directly related to assessing neutropenia.
D. Monitoring the patient's heart rate and reviewing the patient's hemoglobin:
Rationale: Heart rate monitoring and hemoglobin assessment are crucial in various clinical situations but are not specific indicators of neutropenia.
Appropriateness: Not directly related to assessing neutropenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoid the use of moisturizing lotions.
This statement is not a priority instruction. Moisturizing lotions, especially those designed for diabetic foot care, can help prevent dry skin and complications. However, it's crucial to choose appropriate, diabetes-friendly moisturizers.
B. Examine feet weekly for redness, blisters, and abrasions.
This is an important and relevant instruction. Regular foot inspections help detect any signs of injury or infection early, preventing complications, especially for individuals with peripheral neuropathy.
C. Dry feet vigorously after each bath.
This statement is not advisable. Vigorous drying can potentially harm the skin, especially for individuals with diabetes. A gentle and thorough drying is recommended to prevent skin damage.
D. Avoid hot-water bottles and heating pads.
This is a priority instruction. Patients with peripheral neuropathy may have reduced sensation in their feet, making them more susceptible to burns. Avoiding sources of excessive heat helps prevent injuries.
Correct Answer is B
Explanation
A.Regular insulin typically begins to take effect 30 minutes after administration. Administering insulin at the time of the meal (1645) would not allow enough time for the insulin to reach its onset of action, potentially resulting in the blood glucose level being high during the meal.
B.Regular insulin has an onset of action of 30 minutes. By administering the insulin at 1615, it will start to take effect by 1645, when the meal arrives, and help ensure the insulin action aligns with the meal, preventing postprandial hyperglycemia.
C.Administering insulin at 1545 would be too early and could lead to the insulin peaking before the meal, which could result in hypoglycemia if the insulin peak occurs before the patient has food to absorb the glucose.
D.Administering insulin at 1600 would result in the insulin starting to work too soon, with the onset happening before the meal and possibly leading to hypoglycemia if the insulin peaks before the meal is consumed.
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