The nurse is providing care for a client with an absolute neutrophil count (ANC) of 400. Which action should the nurse perform prior to delivering the meal tray to the client's room?
Reference Range
Neutrophils (ANC) [Reference Range: 2500 to 8000 mm3 or 2500 to 8000 cells/uL]
Cut the spaghetti and meatballs into small pieces.
Exchange the pasteurized whole milk with skim milk.
Substitute the fried potatoes with a garden salad.
Remove the fresh grapes from the meal tray.
The Correct Answer is D
Choice A
Cutting the spaghetti and meatballs into small pieces is inappropriate. This choice is not directly related to the risk of infection. It might be helpful for a client who has difficulty swallowing or chewing, but it doesn't address the compromised immune system and infection risk.
Choice B
Exchanging pasteurized whole milk with skim milk is inappropriate. The type of milk doesn't have a direct impact on infection risk. Both pasteurized whole milk and skim milk are considered safe for consumption. This choice doesn't address the specific concern of infection in a client with a low ANC.
Choice C
Substituting fried potatoes with a garden salad is inappropriate. While choosing healthier food options can be beneficial for overall health, the choice between fried potatoes and a garden salad doesn't necessarily impact the infection risk for a client with a low ANC. This choice also doesn't address the specific concern of infection in this context.
Choice D
Remove the fresh grapes from the meal tray is appropriate. The reason for this choice is that a client with an absolute neutrophil count (ANC) of 400 has a significantly compromised immune system, and they are at a high risk of infection due to their low neutrophil count. Neutrophils are a type of white blood cell that plays a crucial role in fighting off infections. A normal ANC falls within the range of 2500 to 8000 mm3 or cells/uL.
Fresh grapes, being a raw and uncooked food item, may carry a higher risk of containing bacteria or pathogens that could pose a threat to a client with such a low ANC. The nurse needs to ensure that the client's exposure to potential sources of infection is minimized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A
"The bruises on my arms are all gone." This statement is incorrect. Bruising can be influenced by various factors, including platelet levels and clotting factors, but it is not a specific sign of Vitamin A deficiency.
Choice B
"My feet don't tingle like they used to. “This statement is incorrect. Tingling feet might be related to nerve function or circulation, but it is not a direct symptom of Vitamin A deficiency.
Choice C
"I can see at night when I wake up now. “This statement is correct. Vitamin A is essential for maintaining good vision, especially in low-light conditions. Deficiency of Vitamin A can lead to a condition called night blindness, where individuals have difficulty seeing in low light. Therefore, the statement "I can see at night when I wake up now" (option C) indicates that an adequate amount of Vitamin A is being provided.
Choice D
"My tummy seems so much smaller now. “This statement is incorrect. Changes in tummy size are not typically related to Vitamin A deficiency. Vitamin A deficiency is more closely associated with symptoms related to vision and immune function.
Correct Answer is D
Explanation
Choice A
Nuts is incorrect. Nuts are a good source of healthy fats, including monounsaturated and polyunsaturated fats, which can actually have a positive impact on heart health. They have been associated with improving HDL cholesterol levels and can be a part of a heart-healthy diet. While nuts are calorie-dense, small portions can be included as part of the client's diet to replace less healthy snacks. Therefore, nuts might not need to be completely avoided.
Choice B
Shellfish Is incorrect. Shellfish, including shrimp, crab, and lobster, are relatively low in saturated fat and cholesterol. While they do contain cholesterol, dietary cholesterol has less impact on blood cholesterol levels compared to saturated and trans fats. The client's main concern is elevated LDL cholesterol, which is influenced more by saturated fat intake. Therefore, avoiding shellfish might not be as crucial as focusing on saturated fat sources.
Choice C
Eggs is incorrect. Eggs are a source of dietary cholesterol, but they also provide essential nutrients. Recent research suggests that dietary cholesterol from foods like eggs has less impact on blood cholesterol levels for most people than was previously thought. For the client, the more significant concern is the elevated LDL cholesterol level. If the client enjoys eggs, they might not need to completely avoid them, but they should consume them in moderation and consider other dietary changes to reduce saturated fat intake.
Choice D
Cheese is correct. Cheese is often high in saturated fats, which can contribute to elevated LDL cholesterol levels. Therefore, it would be important for the client to limit their intake of high-fat cheeses.
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