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 A

Explanation

Choice A

Body mass index (BMI) of 17 is the correct finding. A low Body Mass Index (BMI) is a common indicator of malnutrition. BMI is a measurement that considers a person's weight in relation to their height. A BMI of 17 suggests that the person is underweight, which can be indicative of malnutrition. Malnutrition is characterized by inadequate intake of calories, protein, vitamins, and minerals that are essential for maintaining health and well-being.

Choice B

Decrease in appetite is not correct finding. While a decrease in appetite might contribute to malnutrition, it's a symptom rather than a definitive indicator.

Choice C

Dry mucosal membranes are not the correct finding. Dry mucosal membranes can be related to dehydration or other conditions, but they are not specific enough to confirm malnutrition on their own.

Choice D

Weight of 227 pounds (103 kg) is not the correct finding. This weight is not necessarily indicative of malnutrition on its own. It's important to consider the individual's height, BMI, and other factors when assessing malnutrition.

A. Generalized nonpitting edema. B. Hypoactive bowel sounds in all 4 quadrants. C. Redness at intravenous site. D. Urinary output greater than 30 ml per hour. E. Frequent productive cough.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A

Generalized nonpitting edema is correct. Nonpitting edema could indicate fluid retention, and it's important to assess for signs of fluid overload, electrolyte imbalances, or underlying cardiac issues.

Choice B

Hypoactive bowel sounds in all 4 quadrants is correct. Hypoactive bowel sounds could suggest gastrointestinal motility issues, which could be a sign of gastrointestinal complications related to TPN.

Choice C

Redness at intravenous site is correct. Redness at the intravenous site could be indicative of infection, infiltration, or irritation. It's important to assess for signs of infection and ensure proper IV site care.

Choice D

Urinary output greater than 30 ml per hour is incorrect. While increased urinary output could indicate adequate hydration, it's not typically a concerning finding unless there are other signs of fluid imbalance. Top of Form

Choice E

Frequent productive cough is correct. A frequent productive cough could indicate respiratory issues, including aspiration pneumonia, which can be a complication of TPN.

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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

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","E"]

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]