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 B
Explanation
Choice A
Explain the benefits of a high fibre diet is not correct response. While a high fibre diet can indeed be beneficial for individuals with haemorrhoids by promoting regular bowel movements and reducing strain during defecation, the immediate concern here is addressing the client's understanding about avoiding nuts and seeds. This information could be provided as a follow-up after confirming the client's understanding in response to option B.
Choice B
Confirm that these foods should be avoided is the correct response. In this situation, the nurse's first response should be to confirm the client's understanding and provide accurate information about the need to avoid certain foods. Nuts and seeds can be challenging to digest and may lead to irritation and inflammation in individuals with haemorrhoids. Confirming the client's understanding and providing guidance aligns with the nurse's role in patient education and care.
Choice C
Encourage soft foods such as yogurt is not the correct response. Encouraging soft foods like yogurt is a reasonable suggestion for someone with haemorrhoids, as soft foods are generally easier to digest and less likely to cause irritation. However, the client's statement was specifically about avoiding nuts and seeds. While this choice might be relevant, it doesn't directly address the client's statement.
Choice D
Suggest that the client also avoid fruit skins is not the correct response. This option is not directly related to the client's concern about nuts and seeds. Fruit skins generally contain dietary fibre, which can be beneficial for maintaining regular bowel movements. While some individuals might find that certain fruits with tough skins could exacerbate their haemorrhoid symptoms, this advice might be better suited for a separate discussion about dietary choices rather than as a direct response to the client's statement.
Correct Answer is A
Explanation
Choice A
Serum HDL (high-density lipoprotein) of 35 mg/dL (0.91 mmol/L). Among the options provided, a serum HDL level of 35 mg/dL (0.91 mmol/L) is the assessment data that indicates the need for referral to a nutritionist. HDL is often referred to as "good" cholesterol because it helps remove excess cholesterol from the bloodstream, reducing the risk of cardiovascular disease. In this case, the HDL level of 35 mg/dL is below the recommended reference range for females (greater than 55 mg/dL or greater than 0.91 mmol/L), which could suggest a potential need for dietary and lifestyle interventions to improve cardiovascular health.
Choice B
Serum HbA1c (glycosylated haemoglobin) of 4.8% (0.05) is incorrect. This HbA1c level is within the normal reference range (4% to 5.9%) and indicates good blood sugar control.
Choice C
BMI (body mass index) of 22 kg/m² is incorrect. A BMI of 22 is within the normal weight range and might not necessarily indicate the need for a nutritionist referral.
Choice D
Total serum calcium of 10 mg/dL (2.5 mmol/L) is incorrect. This calcium level is within the normal reference range and might not require a nutritionist referral, unless there are other specific concerns related to calcium intake.
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