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","D","E"]
Explanation
Choice A
Pickles, blackberries, seeds are not appropriate. None of these foods are particularly high in calcium. Pickles and blackberries are not significant sources of calcium, and while some seeds contain calcium, they are not among the best sources.
Choice B
Buttermilk, spinach, milk: These foods are good sources of dietary calcium is appropriate. Milk and buttermilk are commonly consumed dairy products that contain calcium. Spinach, while not as high in calcium as dairy products, still contributes to calcium intake.
Choice C
Pickled olives, spam, nuts are not appropriate. These foods are not known for being high in calcium. Additionally, some foods like pickled olives and spam may have high sodium content, which can affect calcium balance.
Choice D
Fresh meats, fresh turkey, fresh chicken is appropriate. Fresh meats, such as turkey and chicken, provide some calcium, although not as much as dairy products. They also contribute to overall nutritional intake.
Choice E
Cheese spread, processed cheese, cheese is appropriate. Dairy products like cheese, especially processed cheese and cheese spread, are good sources of calcium. They can be effective in increasing calcium intake to address hypocalcaemia.
Correct Answer is C
Explanation
Choice A
Following low carbohydrate diet with low glycaemic index foods is incorrect. This recommendation is not specifically related to the management of glomerulonephritis. While managing carbohydrate intake might be relevant for individuals with diabetes, it's not the primary focus for someone with kidney inflammation.
Choice B
Eating a high protein diet three times a day is incorrect: While protein is important for overall health and recovery, a high protein diet might not be the best recommendation for someone with compromised kidney function. Excessive protein intake could potentially put additional strain on the kidneys.
Choice C
Avoiding foods high in potassium is correct. Examples of foods high in potassium that the client should be cautious about include bananas, oranges, potatoes, tomatoes, spinach, and other fruits and vegetables. Glomerulonephritis is a condition involving inflammation of the glomeruli in the kidneys, which can affect kidney function and the regulation of electrolytes, including potassium. In glomerulonephritis, the kidneys might have difficulty filtering and excreting excess potassium, leading to a potential build-up of potassium in the blood (hyperkalaemia).
Choice D
Restricting sodium rich foods and excessive oral fluids is incorrect. This recommendation aligns more closely with managing fluid retention and blood pressure, which can be relevant for individuals with kidney issues. However, the primary concern in glomerulonephritis is often potassium balance, making the recommendation to avoid high potassium foods more pertinent.
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