A client with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, and the client is experiencing fatigue and mild nausea. Which nursing action is the highest priority?
Assess for sources of bleeding and provide pressure on wounds
Limit contact with infected visitors and place in positive pressure isolation
Administer antiemetics and assess nutrition and hydration status
Monitor energy levels and begin energy-conserving techniques
The Correct Answer is B
A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Levothyroxine is used to replace thyroid hormone in hypothyroidism. Symptoms like tremors, nervousness, and insomnia can indicate that the dose is too high, suggesting possible hyperthyroidism.
B. Weight loss alone is not a primary indicator for adjusting levothyroxine. It is more important to monitor for symptoms of overdosage, such as those described in option A.
C. Levothyroxine does not increase the risk of bleeding. Monitoring is typically focused on thyroid hormone levels rather than bleeding risks.
D. Levothyroxine increases thyroid hormone levels, not decreases them. It is used to supplement the deficient hormone in hypothyroidism.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
- Encephalopathy is a common complication of severe alcohol withdrawal, characterized by altered mental status, confusion, and other neurological symptoms.
- Ammonia levels are often elevated in patients with alcohol withdrawal syndrome, and high ammonia levels can contribute to encephalopathy.
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