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 A

Explanation

Choice A reason: Depression involves social withdrawal, driven by low serotonin or dopamine. Encouraging the client to leave the room and engage socially stimulates oxytocin release and cognitive behavioral benefits, counteracting isolation. This therapeutic approach enhances mood and aligns with depression management goals, making it the most effective response.

Choice B reason: Calling TV a passive activity is partially true but less therapeutic, as it doesn’t directly promote social engagement. Depression treatment prioritizes interpersonal interaction to boost neurotransmitters like serotonin. This response misses the opportunity to encourage social therapy, critical for alleviating depressive symptoms in a mental health setting.

Choice C reason: Suggesting TV sends messages is inappropriate without psychotic symptoms, not indicated in this client’s depression. Depression involves low mood, not delusions. This could confuse or stigmatize, failing to promote social engagement, which is essential for improving mood via neurochemical and behavioral pathways in depression management.

Choice D reason: Allowing unlimited TV outside the room does not address depression’s social isolation. Excessive TV may reinforce withdrawal, reducing therapeutic group activities that enhance serotonin. This lacks focus on active engagement, critical for recovery, making it less effective than encouraging social interaction to improve mental health outcomes.

A. Blood pressure of 100/80 mm Hg. B. Abdominal pulse noted on inspection. C. Urinalysis with 1 to 4 WBC/lpf. D. Urinary output of 30 mL/hour.

Correct Answer is D

Explanation

Choice A reason: A blood pressure of 100/80 mm Hg is low but not specific for renal perfusion without context. Urinary output directly reflects kidney function, with 30 mL/hour indicating possible oliguria. Monitoring output is critical, per renal assessment and acute kidney injury management protocols in nursing care.

Choice B reason: Abdominal pulse on inspection is unrelated to renal perfusion, typically indicating vascular issues like aneurysms. Urinary output is a direct indicator of kidney function, with 30 mL/hour suggesting reduced perfusion. This is irrelevant, per renal assessment and diagnostic standards in nephrology nursing.

Choice C reason: Urinalysis with 1 to 4 WBC/lpf is within normal range and suggests no infection. Urinary output of 30 mL/hour is concerning for decreased renal perfusion, requiring close monitoring. WBCs are less critical, per renal function and acute kidney injury assessment guidelines in nursing.

Choice D reason: Urinary output of 30 mL/hour indicates possible oliguria, a key sign of decreased renal perfusion. Monitoring this parameter assesses kidney function, guiding interventions to prevent acute kidney injury. It is the most direct indicator, per renal perfusion and critical care protocols in nephrology nursing practice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

Correct Answer is A

Explanation

The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter? Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]

Correct Answer is D

Explanation

A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

A client with a history of schizophrenia, and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription?