A nurse is caring for a client who is receiving chemotherapy. The client's most recent lab results show a white blood cell count of 3,100/mm3, and a platelet count of 280,000/mm3. Based on these lab results, which nursing action is appropriate for this client?
Provide the client with an electric shaver for grooming.
Move the client to a negative pressure isolation room.
Encourage the client to select cooked vegetables rather than a salad for their lunch tray.
Educate the client to dab their nose, rather than forcefully blow their nose.
The Correct Answer is A
A. This option is appropriate because the client's low white blood cell count (3,100/mm³) suggests they are at risk for infection due to chemotherapy-induced immunosuppression. Using an electric shaver reduces the risk of cuts and nicks that could potentially lead to infections.
B. This option is not necessary based on the client's current lab results. Negative pressure isolation rooms are typically reserved for clients with severely compromised immune systems, such as those with very low neutrophil counts (neutropenia). A white blood cell count of 3,100/mm³ is within a range where standard precautions are usually sufficient.
C. This option addresses food safety precautions for clients with neutropenia (low white blood cell count). Raw vegetables, including salads, have a higher risk of harboring bacteria that could cause infections. Therefore, cooked vegetables are safer for clients with compromised immune systems.
D. This option is appropriate because chemotherapy-induced thrombocytopenia (low platelet count of 280,000/mm³) increases the risk of bleeding. Forceful blowing of the nose can traumatize the nasal mucosa and increase the risk of nosebleeds. Dabbing the nose gently is a safer method to avoid nosebleeds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Moon face is a common side effect of prednisone, a corticosteroid medication. It results from fluid retention and redistribution of fat in the face. While moon face is a cosmetic concern, it is not typically an urgent or critical finding that requires immediate reporting.
B. Muscle spasticity may develop but does not pose an immediate risk that requires urgent attention.
C. Alcohol consumption can interact with both prednisone and interferon B-1a, potentially leading to increased drug levels in the bloodstream and intensifying side effects. This interaction can also increase the risk of liver problems, which is particularly concerning given that interferon B-1a may cause liver issues.
D. Birth control pills have been a subject of debate regarding their effect on multiple sclerosis but a study found that oral hormonal contraceptives did not appear to be associated with an increased chance of MS relapses.
Correct Answer is C
Explanation
A. Most individuals with Bell's palsy experience gradual improvement within weeks to months, and the majority recover completely. Permanent facial paralysis is rare, but some individuals may have residual mild weakness or asymmetry.
B. This statement is not typically true for Bell's palsy. Antibiotic eye drops are not routinely prescribed unless there is evidence of corneal exposure due to incomplete eyelid closure (lagophthalmos). Instead, artificial tears and lubricating ointments are often recommended to prevent dryness and protect the cornea.
C. In Bell's palsy, weakness or paralysis of the facial muscles can lead to inability to fully close the eyelid on the affected side. Taping the eyelid closed at night helps prevent corneal damage from exposure and dryness.
D. This statement is not recommended. It is important to avoid stressing the affected facial muscles excessively during recovery from Bell's palsy. Chewing evenly on both sides of the mouth is generally recommended to prevent strain and promote balanced muscle function.
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