The nurse includes the problem of “Risk for infection” in the plan of care for a client with myelosuppression. Which laboratory value provides the greatest support for this nursing problem?

Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.69 to 11.17 mmol/L)], Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)], Red Blood Cell Count (RBC) [4.2 to 5.4 x 10⁶/µL (4.2 to 5.4 x 10¹²/L)], White Blood Cell (WBC) [5,000 to 10,000/mm³ (5 to 10 x 10⁹/L)].

Red blood cell count of 3.5 x 10⁶/µL (3.5 x 10¹²/L).

White blood cell count of 1,500/mm³ (1.5 x 10⁹/L).

Hematocrit of 33% (0.33 volume fraction).

Hemoglobin of 10 g/dL (6.21 mmol/L).

Answer and Explanation

The Correct Answer is B

Choice A reason: A red blood cell count of 3.5 x 10⁶/µL indicates anemia from myelosuppression, reducing oxygen transport. RBCs do not fight infection, so this does not support “risk for infection.” Low WBCs impair immune defense, increasing infection susceptibility, making WBC count more relevant to the nursing problem in this context.

Choice B reason: A WBC count of 1,500/mm³ indicates severe leukopenia from myelosuppression, reducing neutrophil production. This impairs immune response, significantly raising infection risk, as pathogens overwhelm the body’s defenses. This lab value directly supports “risk for infection,” necessitating precautions like isolation or antibiotics to prevent opportunistic infections.

Choice C reason: Hematocrit of 33% reflects anemia in myelosuppression, lowering oxygen delivery. This causes fatigue but does not increase infection risk, as RBCs are not immune cells. WBCs, particularly neutrophils, are critical for infection defense, making low WBC count more relevant to the nursing problem than hematocrit.

Choice D reason: Hemoglobin of 10 g/dL indicates anemia, reducing oxygen-carrying capacity in myelosuppression. This does not directly increase infection risk, as hemoglobin is not involved in immunity. Low WBCs compromise pathogen defense, making WBC count the key value supporting “risk for infection” in this client’s care plan.

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Correct Answer is C

Explanation

Choice A reason: Measuring abdominal girth monitors distention but is less critical before digital removal of a fecal impaction. Impaction causes constipation, but girth changes are slow. Vital signs detect autonomic responses like bradycardia from vagal stimulation during the procedure, making them more urgent to ensure safety.

Choice B reason: Bowel sounds indicate motility, reduced in impaction, but do not predict complications during digital removal, which risks vagal stimulation causing bradycardia. Vital signs are critical, detecting cardiovascular instability, ensuring safety during this invasive procedure, making bowel sounds less immediate for assessment.

Choice C reason: Assessing vital signs is essential, as digital removal stimulates rectal nerves, potentially triggering a vagal response, causing bradycardia or hypotension. This risks syncope or shock. Monitoring heart rate and blood pressure ensures cardiovascular stability, preventing complications during this procedure, addressing autonomic risks effectively.

Choice D reason: Breath sounds assess respiratory status, unrelated to fecal impaction removal, a gastrointestinal issue. The procedure risks vagal stimulation, not pulmonary effects. Vital signs detect cardiovascular changes like bradycardia, ensuring safety during rectal manipulation, making breath sounds irrelevant for this assessment.

A. Position the sterile field even with the nurse’s hips. B. Clean the urinary meatus before retracting the foreskin. C. Use a swab to wipe the meatus in backward strokes. D. Advance the catheter before inflating the balloon.

Correct Answer is B

Explanation

Choice A reason: Positioning the sterile field at hip level maintains sterility but is not specific to uncircumcised clients. Cleaning the meatus before retracting the foreskin prevents infection by removing bacteria first. This is secondary, per infection control and catheterization procedure standards in nursing practice.

Choice B reason: Cleaning the meatus before retracting the foreskin removes bacteria, reducing infection risk in uncircumcised clients. This sequence ensures sterility before exposing sensitive areas, critical for preventing urinary tract infections, per evidence-based catheterization and infection control protocols in urological nursing care.

Choice C reason: Wiping the meatus in backward strokes is incorrect, as circular strokes from meatus outward are standard to avoid contamination. Cleaning before retracting the foreskin is critical for infection prevention. This violates sterile technique, per catheterization and infection control standards in nursing.

Choice D reason: Advancing the catheter before inflating the balloon is standard but not specific to uncircumcised clients. Cleaning the meatus first addresses foreskin-related infection risks. Balloon inflation timing is universal, per indwelling catheter insertion and urological care protocols in nursing practice.

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Naxlex Comprehensive Predictor Exams

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Correct Answer is C

Explanation

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

Correct Answer is B

Explanation

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

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