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. A vegetarian diet typically does not directly contribute to bronchoconstriction. In fact, a diet rich in fruits and vegetables may provide antioxidants and anti-inflammatory compounds that can be beneficial for respiratory health. Therefore, this option is less likely to be a cause of the client's bronchoconstriction.
B. Rosuvastatin (and other statins) are generally well-tolerated, but some individuals may experience respiratory side effects, including cough or shortness of breath. However, bronchoconstriction as a direct side effect of statins is uncommon and typically not a primary concern unless there is a rare hypersensitivity reaction.
C. Propranolol is a non-selective beta-blocker that can lead to bronchoconstriction, particularly in individuals with asthma or other respiratory conditions. Beta-blockers can block beta-2 receptors in the lungs, potentially causing constriction of the airways and worsening of respiratory symptoms.
D. Acetaminophen (paracetamol) is generally considered safe and does not typically cause bronchoconstriction. It is a non-steroidal anti-inflammatory drug (NSAID) that works differently from medications like beta-blockers, which directly affect the airways.
Correct Answer is A
Explanation
A. Retropulsion is a classic manifestation of postural instability in Parkinson's disease. It refers to a tendency to lose balance and fall backward, especially when attempting to initiate walking or when challenged with external forces.
B. Impaired handwriting, also known as micrographia, is associated with bradykinesia (slowness of movement) in Parkinson's disease. It manifests as progressively smaller and more cramped handwriting.
C. Muscle soreness and pain can occur in Parkinson's disease, but they are not typically directly associated with postural instability. They may occur due to rigidity (muscle stiffness) or abnormal postures maintained over time.
D. Slow movements, or bradykinesia, are a hallmark feature of Parkinson's disease and are characterized by a gradual reduction in the speed and fluidity of voluntary movements. While related to motor symptoms in Parkinson's disease, slow movements are not specific to postural instability.
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