A client admitted to a medical-surgical unit has a CBC with differential drawn. Lab results show a WBC count of 4,000 with neutrophil segments at 5% and neutrophil bands at 5%. Based on these values, what will the nurse do? Calculate the absolute neutrophil count.
Place the client in a private room.
Collect blood cultures and start antibiotics.
Place the client on bleeding precautions.
Document findings in the client’s chart
The Correct Answer is A
A. Place the client in a private room: The absolute neutrophil count (ANC) is calculated as the total WBC × (% segs + % bands). Here, ANC = 4,000 × (0.05 + 0.05) = 400, indicating severe neutropenia (ANC < 500). This places the client at high risk for infection, so the nurse should initiate neutropenic precautions, including private room placement and infection control measures.
B. Collect blood cultures and start antibiotics: Although neutropenic clients are at increased risk for infection, there is no indication in the question that the client currently exhibits fever or infection signs. Prophylactic antibiotics are not started without clinical evidence of infection or physician order.
C. Place the client on bleeding precautions: Bleeding precautions are appropriate for clients with thrombocytopenia, not neutropenia. The CBC provided shows a low WBC count but does not mention low platelets, so bleeding risk is not the concern here.
D. Document findings in the client’s chart: While documentation is necessary, it is not the priority action. The client’s critically low ANC requires immediate implementation of protective isolation to prevent infection before routine charting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assess the client’s respiratory status: Respiratory compromise is the most immediate threat in acute heart failure exacerbation due to pulmonary congestion and edema. Evaluating oxygenation, breath sounds, and work of breathing is the priority for client safety.
B. Draw blood to assess the client’s serum electrolytes: Electrolyte assessment is important for ongoing management, especially with diuretic therapy, but it is not the immediate priority over assessing airway and breathing.
C. Ask the client about current medications: Medication history helps guide treatment, but it does not address the most urgent physiological threat.
D. Administer intravenous furosemide: IV diuretics are used to reduce fluid overload, but they should be given after assessing the client’s respiratory and hemodynamic status to ensure safe administration.
Correct Answer is A
Explanation
Calculation:
- Identify the Order and the Available medication:
Ordered Dose (D) = 0.25 mg
Available Dose (H) = 0.1 mg
Quantity (Q) = 1 mL
Volume (mL) = (Dose Ordered (D) / Dose Available (H)) x Quantity (Q)
= (0.25 mg / 0.1 mg) x 1 mL
= 2.5 mL
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