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 C

Explanation

C. Breakthrough pain is a transient exacerbation of pain that occurs despite the use of around- the-clock analgesics for persistent pain. Breakthrough pain episodes require rapid intervention with additional analgesics or adjustments to the current pain management regimen to provide adequate pain relief and improve the client's quality of life.
A. Replacing transdermal analgesic patches every 72 hours is important for ensuring consistent delivery of medication, but it is not directly related to addressing breakthrough pain.
B. Administering analgesics on a fixed and continuous schedule is important for maintaining baseline pain control, but it may not address breakthrough pain adequately.
D. Frequently evaluating the client's pain is essential, but monitoring specifically for breakthrough pain ensures timely intervention when pain exacerbations occur.

A. Carefully cleans and peels all fresh fruit and vegetables. B. Uses only lactose free dairy products. C. Enjoys fat free yogurt as an occasional snack food. D. No longer includes grains in daily diet.

Correct Answer is C

Explanation

C. The DASH eating plan emphasizes consumption of fruits, vegetables, low-fat dairy products, whole grains, lean proteins, and limited amounts of saturated fats, cholesterol, and sodium. Therefore, enjoying fat-free yogurt as an occasional snack food aligns with the principles of the DASH eating plan.

A. is a good practice for food safety but does not specifically indicate adherence to the DASH eating plan. The DASH plan encourages consumption of fruits and vegetables but does not require meticulous cleaning or peeling.
B. may be suitable for individuals with lactose intolerance but is not a specific requirement of the DASH eating plan. The DASH plan recommends low-fat or fat-free dairy products but does not specify lactose-free products.
D. The DASH plan encourages consumption of whole grains as part of a balanced diet and recommends incorporating whole grains such as whole wheat, brown rice, and oats.

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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

A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the dient is adhering to the eating plan?

Correct Answer is C

Explanation

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In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize?

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)]