The nurse includes the problem of "Risk for infection" in the plan of care for a client with myelosuppression. Which laboratory value of care 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 10/μL (4.2 to 5.4 x 1012/L)] White Blood Cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 10"/L)]

Hematocrit of 33% (0.33 volume fraction).

White blood cell count of 1,500/mm3 (1.5 x 10°)

Hemoglobin of 10 g/dl (6.21 mmol/L)

Red blood cell count of 3.5 x 10l(3.5 x 10").

Answer and Explanation

The Correct Answer is B

A.   Hematocrit measures the proportion of blood volume that is occupied by red blood cells. A hematocrit of 33% is lower than the normal range (42% to 52% for males and 37% to 47% for females). While this indicates anemia and reduced oxygen-carrying capacity of the blood, it is not directly related to the risk for infection.
B.   White blood cells (WBCs) are crucial for the immune system and fighting infections. A WBC count of 1,500/mm³ is significantly below the normal range (5,000 to 10,000/mm³). This low WBC count, also known as leukopenia, indicates a decreased ability to fight infections, making the client highly susceptible to infections.
C.   Hemoglobin measures the oxygen-carrying capacity of red blood cells. A hemoglobin level of 10 g/dL is below the normal range (14 to 18 g/dL), indicating anemia. While anemia affects overall health and can contribute to fatigue and weakness, it does not directly indicate the risk for infection.
D.   The red blood cell (RBC) count measures the number of red blood cells in the blood. A count of 3.5 x 10^12/L is below the normal range (4.2 to 5.4 x 10^12/L), indicating a reduction in red blood cells and anemia. Like low hemoglobin, this value indicates anemia but does not directly reflect the risk for infection.

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Correct Answer is D

Explanation

A. Anxiety is a common symptom in patients with thyrotoxicosis due to increased metabolic activity and overstimulation of the nervous system. While anxiety can be distressing, it is not typically life- threatening and does not usually require immediate intervention.
B. Hyperglycemia (high blood glucose levels) can occur in patients with thyrotoxicosis due to increased metabolic rate and potential effects on insulin sensitivity. It requires monitoring and management but typically does not demand immediate intervention unless it is severe and causing other complications.
C. Fever can be a sign of thyroid storm, a severe form of thyrotoxicosis that can be life-threatening. Elevated body temperature in the context of thyrotoxicosis requires prompt assessment as it may indicate an underlying severe condition or complications.
D. Dyspnea is a critical symptom that warrants immediate intervention. In the context of thyrotoxicosis, it may indicate a severe complication such as heart failure, thyroid storm, or respiratory distress. Given that dyspnea can lead to compromised oxygenation and potentially life-threatening situations, it is the most urgent symptom to address.

A. Straining on urination and nocturia B. Azotemia and anorexia. C. Hematuria and proteinuria. D. Fever and dysuria.

Correct Answer is D

Explanation

A. These symptoms indicate a urinary tract issue but do not necessarily indicate a high risk for injury. While they are uncomfortable, they do not typically lead to physical harm.
B. Azotemia is the build-up of waste products in the blood, and anorexia is a loss of appetite. These symptoms indicate a more severe kidney problem and do not specifically point to an increased risk of injury due to a potential UTI.
C. These symptoms suggest kidney involvement but do not necessarily indicate an imminent risk of injury. While they are important to address, they do not warrant the nursing problem of "high risk for injury due to potential urinary tract infection."

D. Fever and dysuria are classic symptoms of a urinary tract infection (UTI). A UTI can progress to a more serious infection, such as pyelonephritis, which can lead to sepsis and potentially life-threatening complications. Therefore, these symptoms indicate a high risk for injury due to the potential for a UTI to worsen.

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Naxlex Comprehensive Predictor Exams

A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is D

Explanation

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

Correct Answer is D

Explanation

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

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