A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range:

Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]

Review need for pneumococcal vaccine.

Implement bleeding precautions.

Place the client in protective isolation.

Assess vital signs every 4 hours.

Answer and Explanation

The Correct Answer is C

C. An ANC of 500/mm3 (0.5 x 10/L) is indicative of severe neutropenia, which places the client at a significantly increased risk of developing infections due to the decreased ability of the immune system to fight off pathogens. Placing the client in protective isolation is essential to minimize the risk of exposure to infectious agents that could lead to severe infections
A. While reviewing the need for pneumococcal vaccine is important for preventing infections in immunocompromised clients, it may not be the most immediate priority in this scenario.
B. Implementing bleeding precautions is relevant for clients with thrombocytopenia but is not the most critical intervention for a client with severe neutropenia.
D. Assessing vital signs every 4 hours is a routine nursing intervention, but it may not directly address the heightened risk of infection associated with severe neutropenia.

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Correct Answer is B

Explanation

B. Changes in hematocrit (red blood cell count) and blood pressure can indicate potential complications or changes in the client's condition, such as internal bleeding or rupture of the aneurysm. Therefore, communicating hematocrit and blood pressure values would be important for the healthcare provider to assess in this situation.
A. While calcium level and skin condition are important aspects of overall health, they may not be directly relevant to the assessment of low back pain in a client with an abdominal aortic aneurysm. Therefore, this information may not be the most critical for the healthcare provider to assess in this specific situation.
C. These parameters are also important for assessing a client's condition, especially in the context of potential infection or systemic inflammation. However, they may not be directly related to the specific symptom of low back pain in a client with an abdominal aortic aneurysm. While changes in white blood cell count and pulse rate could indicate infection or other complications, they may not be the most critical information to communicate in this scenario.
D. While serum amylase levels and level of consciousness are important indicators of pancreatic function and neurological status, respectively, they may not be directly related to the symptom of low back pain in a client with an abdominal aortic aneurysm. Therefore, these parameters may not be the most critical information to communicate in this situation.

A. Sputum culture positive for Mycobacterium tuberculosis. B. Hemoccult test on sputum collected from hemoptysis. C. Chest x-ray or computed tomography (CT). D. Positive purified protein derivative (PPD) skin test.

Correct Answer is A

Explanation

A. This choice involves culturing a sputum sample collected from the patient to identify the presence of Mycobacterium tuberculosis, the bacterium that causes tuberculosis. A positive result confirms the diagnosis of TB.
B. Hemoccult tests are used to detect hidden (occult) blood in stool samples. While hemoptysis (coughing up blood) can be a symptom of TB, a hemoccult test is not specific for TB diagnosis. It is more commonly used in detecting gastrointestinal bleeding.
C. Imaging studies like chest x-ray or CT scans can reveal abnormalities in the lungs suggestive of TB, such as infiltrates, cavitations, or lymph node enlargement. While these tests can support the diagnosis, they are not definitive on their own.
D. The PPD skin test is a common screening tool for TB exposure. It detects the presence of a delayed hypersensitivity reaction to proteins derived from Mycobacterium tuberculosis. A positive PPD indicates exposure to TB but does not confirm active disease.

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A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]

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Naxlex Comprehensive Predictor Exams

The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

Correct Answer is B

Explanation

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Correct Answer is A

Explanation

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

Five months following treatment for herpes zoster, an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

A client experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?

A client who fractured the right femur from a fall at home is placed in traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement?

In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

Review Hand P and laboratory results Exhibits What item(s) should be included in the treatment regimen for this client? Select all that apply.

The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

Patient Data Exhibits Based on the laboratory data, the client has dropdown related to dropdown

A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range:

Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]