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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Peptic ulcer disease involves the formation of open sores in the lining of the stomach or the duodenum. The characteristic symptom of PUD is abdominal pain, typically located in the upper mid abdomen. This pain is often described as gnawing, burning, or aching in nature. The pain may occur shortly after eating, especially when the stomach is empty (gastric ulcer), or it may occur 2-3 hours after eating, typically at night (duodenal ulcer).
A. describes symptoms more suggestive of irritable bowel syndrome (IBS) or gastrointestinal sensitivity to spicy foods, leading to cramps and diarrhea, but it is less specific to PUD.
B. indicates frequent use of antacids for indigestion, which may suggest symptoms of acid reflux or gastritis but do not specifically point to the presence of peptic ulcers.
D. suggests more severe systemic issues such as malignancy or chronic diseases rather than solely PUD.
Correct Answer is B
Explanation
B. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. Elevated serum creatinine levels may indicate impaired kidney function. Since contrast agents can affect renal function, a serum creatinine level above the reference range should be reported to the healthcare provider before the MRI with contrast.
A. While elevated blood sugar levels may indicate diabetes or poor glycemic control, they are not directly related to kidney function or the risk of contrast-induced nephropathy. Therefore, this value is not the most pertinent for reporting before an MRI with contrast.
C.Glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past two to three months and is used to assess long-term glycemic control in diabetes. While elevated HbA1c levels suggest poor diabetes management, they do not directly assess kidney function or the risk of contrast-induced nephropathy.
D. Blood urea nitrogen (BUN) levels reflect the amount of urea nitrogen in the blood and can indicate kidney function. Elevated BUN levels may suggest impaired renal function. However, an elevated serum creatinine is a more reliable marker for renal excretion.
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