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. Cholelithiasis (gallstones) is a known risk factor for acute pancreatitis, as gallstones can block the bile duct and lead to inflammation of the pancreas.
B. Addison disease is not directly associated with an increased risk of acute pancreatitis. It primarily affects adrenal gland function.
C. Hypothyroidism does not typically influence the risk of developing acute pancreatitis. The condition primarily affects metabolism.
D. Gout is a condition related to elevated uric acid levels and is not a direct risk factor for acute pancreatitis.
Correct Answer is ["B","C","D","E"]
Explanation
A. Osteoarthritis is not associated with hearing loss
B. The client's place of employment as a firearms instructor at a shooting range exposes them to loud noises, which is a well-known risk factor for hearing loss.
C. Gentamycin is an aminoglycoside antibiotic that can be ototoxic, especially when administered in high doses or for prolonged periods, potentially leading to hearing loss.
D. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that has been associated with an increased risk of hearing loss, particularly when taken regularly or in high doses.
E. Bumetanide is a loop diuretic that can also have ototoxic effects, especially when used in conjunction with aminoglycoside antibiotics like gentamycin.
F. Heart failure is not associated with hearing loss
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