A nurse is caring for a 75.year.old male client who is experiencing difficulty breathing and shortness of breath.

Exhibits

The nurse is caring for the client following a thoracentesis. Select the 3 findings that require immediate follow.up.

A. Increase raw produce in the client's diet. Clients with an absolute neutrophil count (ANC) <1,000/mm³ are at high risk for infection due to neutropenia. Raw produce, including fruits and vegetables, may contain bacteria or fungi that could lead to infections. These clients should follow a neutropenic diet, which includes cooked foods and avoids raw or undercooked items.
B. Limit visitors to healthy adults. This is the most appropriate intervention. Clients with severe neutropenia (ANC <1,000/mm³) have a significantly weakened immune system and are highly susceptible to infections. Restricting visitors to only healthy adults reduces the risk of exposure to pathogens. Additionally, visitors should follow proper hand hygiene and wear a mask if necessary to prevent transmission of infectious agents.
C. Instruct the client to floss his teeth daily. Flossing can cause minor gum trauma, increasing the risk of bacterial entry and infection in neutropenic clients. Instead of flossing, the client should use a soft toothbrush and practice gentle oral hygiene to minimize the risk of oral mucosal injury and subsequent infection.
D. Take the client's rectal temperature each day. Rectal temperature measurement is contraindicated in neutropenic clients due to the risk of mucosal injury and bacterial translocation, which can lead to bloodstream infections (bacteremia). Instead, the client’s temperature should be monitored using an oral or tympanic thermometer to detect early signs of infection.

A. "DIC is controllable with lifelong heparin usage." Heparin may be used in certain cases to interrupt the coagulation cascade, but DIC is an acute, secondary condition requiring treatment of the underlying cause rather than longterm anticoagulation therapy.
B. "DIC is caused by abnormal coagulation involving fibrinogen." DIC results from widespread activation of the coagulation system, leading to excessive fibrin deposition, consumption of clotting factors, and fibrinolysis. This leads to microvascular thrombosis and subsequent bleeding due to depletion of fibrinogen, platelets, and other clotting components.
C. "DIC is a genetic disorder involving a vitamin K deficiency." DIC is an acquired condition triggered by severe infections, trauma, malignancy, or obstetric complications. It is not a hereditary disorder and is unrelated to vitamin K deficiency, which primarily affects the production of clotting factors II, VII, IX, and X.
D. "DIC is characterized by an elevated platelet count." DIC leads to widespread platelet consumption, resulting in thrombocytopenia rather than thrombocytosis. The depletion of clotting factors and platelets contributes to an increased risk of bleeding, prolonged clotting times, and potential multiorgan dysfunction.