The nurse is caring for a patient with leukemia who has an absolute neutrophil count (ANC) of 500/mm³. What interventions will the nurse include in the plan of care for this patient related to this finding? Select All That Apply.

Administer filgrastim (granulocyte colony stimulating factor (G-CSF)) as ordered.

Keep the patient's central line insertion site clean and open to air.

Educate the patient and family about food safety and hygiene.

Provide a high-protein, high-calorie diet.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale

Administering filgrastim (G-CSF) as ordered is crucial for patients with a low ANC. Filgrastim stimulates the production of neutrophils in the bone marrow, helping to reduce the risk of infections. For a patient with an ANC of 500/mm³, which indicates severe neutropenia, this intervention can significantly enhance the immune response and decrease susceptibility to infections.

Choice B rationale

Keeping the patient's central line insertion site clean and open to air is incorrect and could increase the risk of infection. Central line sites must be covered with a sterile dressing to prevent bacterial contamination and infection. Open exposure to air can introduce pathogens, especially in a patient with neutropenia.

Choice C rationale

Educating the patient and family about food safety and hygiene is essential for preventing infections in patients with neutropenia. Proper food handling and hygiene practices reduce the risk of bacterial and other infections. This education can help patients and their families implement measures to protect the patient from potential sources of infection.

Choice D rationale

Providing a high-protein, high-calorie diet is appropriate for supporting the patient's overall health and recovery. High-protein and high-calorie foods support the body's immune function, repair tissues, and maintain energy levels. Proper nutrition is vital for patients with leukemia to help them cope with the demands of their illness and treatment.

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Correct Answer is B

Explanation

Choice A rationale

Chemotherapy and radiation can significantly affect fertility. It would be incorrect to reassure the patient that these treatments will not impact her ability to become pregnant, as these treatments often reduce fertility or cause temporary or permanent infertility.

Choice B rationale

Discussing fertility counseling and contraception options allows the patient to make informed decisions about her reproductive health. Fertility preservation methods, such as egg or embryo freezing, can be considered before starting treatment. This approach respects the patient's desire to become pregnant while acknowledging the impact of cancer treatment.

Choice C rationale

Referring the patient to a social worker for pregnancy surrogacy is premature and not directly addressing the patient's immediate concerns about fertility and treatment. Fertility counseling is a more appropriate initial step.

Choice D rationale

Delaying treatment for cancer to allow for pregnancy can have severe negative impacts on the patient's prognosis and is not advised. Immediate treatment is crucial to control the disease and improve survival chances.

A. Insert nasogastric tube and begin enteral feeding. B. Teach the patient to increase protein intake and to eat five to seven times a day. C. Implement strict NPO status and initiate total parenteral nutrition (TPN). D. Teach the patient to rinse their mouth with alcohol-based mouthwash prior to meals.

Correct Answer is A

Explanation

Choice A rationale

For a client with severe malnutrition, immediate intervention is necessary to address nutritional deficiencies. Inserting a nasogastric tube and beginning enteral feeding is the first step to provide essential nutrients, stabilize the patient's condition, and prevent further complications from malnutrition.

Choice B rationale

Teaching the patient to increase protein intake and to eat more frequently is important but not the immediate priority in a case of severe malnutrition. This can be addressed after initial stabilization and nutritional support.

Choice C rationale

Total parenteral nutrition (TPN) is an option for patients who cannot tolerate enteral feeding, but initiating strict NPO status without first attempting enteral feeding is not the best initial approach. Enteral feeding is generally preferred if the gastrointestinal tract is functional.

Choice D rationale

Rinsing the mouth with alcohol-based mouthwash before meals is not a priority in managing severe malnutrition. It does not address the immediate need for nutritional support and could be harmful if ingested.

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The nurse is caring for a patient with leukemia who has an absolute neutrophil count (ANC) of 500/mm³. What interventions will the nurse include in the plan of care for this patient related to this finding? Select All That Apply.

Nursing Test Bank

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