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 ["1.6"]
Explanation
To determine how many milliliters (mL) of diazepam the nurse should administer to the client, first, we need to calculate the amount of medication needed for each dose.
The prescribed dose is 8 mg of diazepam.
Volume= Desired dose/available concentration per ml
Available concentration per ml= 10mg/2ml Available concentration per ml= 5mg/ml Volume= 8mg/5mg per ml
Volume= 1.6ml
So, the nurse should administer 1.6 mL of diazepam to the client.
Correct Answer is ["A","C","E"]
Explanation
A. Standard precautions should always be followed when caring for any patient to prevent the transmission of infectious agents. Additionally, wearing a mask can provide further protection, especially if there is a risk of respiratory droplet transmission.
C. Culturing the wound drainage allows for the identification of the specific bacteria causing the infection, including whether it is methicillin-resistant Staphylococcus aureus (MRSA). Sensitivity testing helps determine which antibiotics are effective against the bacteria, guiding appropriate antibiotic therapy.
E. Contact precautions are necessary for preventing the transmission of MRSA to other patients, staff, and visitors. This includes wearing gloves and gowns when providing care, as well as ensuring proper hand hygiene practices. Visitors may also need to follow specific precautions to prevent the spread of infection.
B. While monitoring the client's white blood cell count may be important for assessing the body's response to infection, it is not specific to MRSA infection. MRSA infection is typically diagnosed based on clinical presentation and confirmed through laboratory tests such as wound cultures.
D. A low bacteria diet is not typically indicated for MRSA infection. MRSA is primarily treated with antibiotics, and dietary modifications are not a standard part of its management.
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