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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A

Bananas are incorrect. Bananas are naturally low in sodium.

Choice B

Ground sirloin is correct. For an older adult who needs to limit sodium intake, the nurse should encourage avoiding foods that are high in sodium. Processed meats, including ground meats like ground sirloin, are often higher in sodium due to added preservatives and flavourings. These additives can significantly contribute to sodium content. Encouraging the client to choose lean meats and to avoid processed meats can help reduce sodium intake.

Choice C

Cottage cheese is incorrect. While cottage cheese might contain some sodium, it's usually lower in sodium compared to processed meats.

Choice D

Broccoli is incorrect. Broccoli is a vegetable that is naturally low in sodium.

A. Describe the value of eating smaller portion sizes. B. Encourage a well-balanced diet and moderate exercise. C. Explore the reasons the client wants to lose weight. D. Determine if the client has a history of anorexia.

Correct Answer is B

Explanation

Choice A

Describing the value of eating smaller portion sizes is not appropriate. While portion control is important, this advice alone might not address the overall dietary quality and exercise component necessary for effective weight loss.

Choice B

Encouraging a well-balanced diet and moderate exercise is appropriate. This intervention focuses on promoting healthy and sustainable weight loss. A well-balanced diet helps ensure that the client is getting all the necessary nutrients while aiming for a calorie deficit for weight loss. Moderate exercise complements dietary changes and contributes to overall health and weight management.

Choice C

Exploring the reasons, the client wants to lose weight is inappropriate. While understanding the client's motivations is valuable, this doesn't directly provide guidance on how to achieve the goal of losing 10 pounds.

Choice D

Determining if the client has a history of anorexia is inappropriate. While assessing for eating disorders is important in general, assuming there's no indication of anorexia, the focus should be on providing guidance for safe and effective weight loss.

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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]

Nursing Test Bank

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Correct Answer is B

Explanation

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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]