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 C
Explanation
A. Vitamin A Deficiency:
Symptoms: Enlarged tongue and smooth, beefy red appearance.
Relevance: Vitamin A deficiency is not typically associated with an enlarged tongue. It is more commonly linked to night blindness and skin issues.
B. Folic Acid Deficiency:
Symptoms: Enlarged tongue and smooth, beefy red appearance.
Relevance: Folic acid deficiency can lead to megaloblastic anemia and glossitis (inflammation of the tongue), which may present as an enlarged, smooth, and red tongue.
C. Vitamin B12 Deficiency:
Symptoms: Enlarged tongue and smooth, beefy red appearance.
Relevance: Vitamin B12 deficiency can cause pernicious anemia and glossitis, resulting in an enlarged, smooth, and red tongue.
D. Vitamin C Deficiency:
Symptoms: Not typically associated with an enlarged tongue.
Relevance: Vitamin C deficiency is more commonly associated with symptoms like scurvy, which includes bleeding gums, joint pain, and skin issues, but not specifically an enlarged tongue.
Correct Answer is D
Explanation
A. Aspirin Toxicity:
Effect on Blood Gases: Aspirin toxicity can cause respiratory alkalosis due to increased respiratory rate (hyperventilation), leading to a decreased PaCO2 and increased pH.
Relation to Given Blood Gases: It could potentially cause the observed blood gas values (low PaCO2 and high pH), making it a possible cause.
B. Fever:
Effect on Blood Gases: Fever might cause hyperventilation, resulting in respiratory alkalosis with decreased PaCO2 and increased pH.
Relation to Given Blood Gases: It could potentially cause the observed blood gas values.
C. Anxiety Attack:
Effect on Blood Gases: Anxiety attacks can lead to hyperventilation and subsequent respiratory alkalosis with low PaCO2 and high pH.
Relation to Given Blood Gases: It could potentially cause the observed blood gas values.
D. Chronic Obstructive Pulmonary Disease (COPD):
Effect on Blood Gases: COPD typically causes respiratory acidosis due to impaired gas exchange, resulting in elevated PaCO2 and decreased pH.
Relation to Given Blood Gases: COPD wouldn't typically cause the observed blood gas values of low PaCO2 and high pH.
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