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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Absence of pulmonary and peripheral edema is not a primary goal of vasopressor therapy. The focus is on improving blood pressure and perfusion.
B. Vasopressor therapy aims to increase blood pressure, not reduce stroke volume or cardiac output.
C. Vasopressors are used to increase blood pressure, so reducing blood pressure is not an intended goal.
D. The primary goal of vasopressor therapy in septic shock is to maintain an adequate mean arterial pressure (MAP) to ensure adequate organ perfusion and prevent organ failure.

A. Difficulty swallowing B. Pain of 9 on a scale of 0 to 10 C. Respiratory rate 24 breaths per minute D. Urinary output of 25 mL/hr

Correct Answer is A

Explanation

A. Difficulty swallowing in a client with facial burns can indicate airway compromise due to edema and should be reported immediately as it may require urgent intervention to secure the airway.
B. While pain is a significant concern and should be managed, it is not as immediately life-threatening as potential airway obstruction.
C. A respiratory rate of 24 breaths per minute is elevated but within the range of mild tachypnea, which could be due to pain or anxiety, and is not the most urgent finding.
D. Urinary output of 25 mL/hr is below normal and indicates possible hypovolemia or kidney injury, but airway concerns take precedence in this scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The critical care nurse is preparing to initiate an infusion of a vasopressor medication to a client in septic shock. What goal of this treatment should the nurse identify?

Correct Answer is D

Explanation

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the healthcare provider?

Correct Answer is A

Explanation

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