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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Administering a PRN narcotic at 9 cm dilation is inappropriate, as labor is in transition, nearing delivery. Narcotics risk fetal respiratory depression, crossing the placenta, especially with a stable fetal heart rate (120 beats/minute). Preparing for imminent delivery is critical, prioritizing a safe birth environment over pain relief.

Choice B reason: Asking the husband to leave does not address the client’s advanced labor (9 cm, 100% effaced, frequent contractions). His presence may provide support, and removal could increase distress. Setting up the delivery table is urgent, as birth is imminent, ensuring a sterile, safe environment for delivery.

Choice C reason: At 9 cm dilation, 100% effacement, and contractions every 2 minutes, the client is in transition, with delivery imminent. Setting up the delivery table ensures readiness for vaginal birth, providing a sterile field and equipment, addressing the physiological progression of labor for safe delivery of the newborn.

Choice D reason: Notifying the rapid response team is unnecessary, as the fetal heart rate (120 beats/minute) is normal (110–160), and screaming reflects labor pain. Delivery is imminent, making table setup the priority to facilitate safe birth, avoiding escalation to emergency response for a normal labor progression.

A. Orientation to person and place only. B. Unequal bilateral hand grip strengths. C. Left-sided facial drooping and dysphagia. D. Pupillary changes to ipsilateral dilation.

Correct Answer is D

Explanation

Choice A reason: Orientation to person and place only suggests confusion, common in right hemisphere stroke affecting non-dominant cognition. This is not immediately life-threatening. Pupillary dilation indicates increased intracranial pressure (ICP) or herniation, a critical emergency requiring urgent intervention to prevent brain stem damage or death.

Choice B reason: Unequal hand grip strengths indicate hemiparesis, typical in right hemisphere stroke affecting left-sided motor function. This is expected and not acutely life-threatening. Pupillary dilation signals rising ICP or herniation, necessitating immediate intervention to prevent catastrophic neurological decline, making it the priority finding.

Choice C reason: Left-sided facial drooping and dysphagia are common in right hemisphere stroke, reflecting contralateral cranial nerve deficits. These are serious but not immediately life-threatening. Pupillary dilation indicates potential herniation from ICP, requiring urgent intervention like mannitol to prevent brain stem compression and fatal outcomes.

Choice D reason: Ipsilateral pupillary dilation in right hemisphere stroke signals increased ICP or herniation, compressing the oculomotor nerve (CN III), impairing pupillary constriction. This life-threatening emergency indicates impending brain stem compromise, requiring immediate intervention with ICP-lowering measures or surgery to prevent irreversible damage or death.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

Correct Answer is C

Explanation

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Correct Answer is D

Explanation

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

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

Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

A client with heart failure is receiving intravenous fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?

Following a total thyroidectomy, the nurse plans to observe a client for complications. Which finding indicates that the client has developed a complication?

The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?

An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?