A nurse is caring for a client who is receiving cisplatin for the treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client?
- WBC: 1,400/mm³
- RBC: 4.3 x 10¹²/L
- Hgb: 12.1 g/dL
- Hct: 36.5%
- Platelets: 170,000/mm³
- Albumin: 4.5 g/dL
Given the options:
The client should receive an erythropoiesis-stimulating agent.
The client should receive a diet with increased protein.
The client has an increased risk of infection.
The client has an increased risk for bleeding.
The Correct Answer is C
Choice A reason: The use of erythropoiesis-stimulating agents (ESAs) is indicated for anemia due to chemotherapy¹. However, the client's hemoglobin (Hgb) level is 12.1 g/dL, which is within the normal range (normal: 12-15.5 g/dL for women). Therefore, administering an ESA is not indicated based on the Hgb level provided.
Choice B reason: A diet with increased protein can be beneficial for patients undergoing chemotherapy as it helps in tissue repair and immune system function. However, the client's albumin level is 4.5 g/dL, which falls within the normal range (normal: 3.4-5.4 g/dL), suggesting adequate protein intake. Thus, there is no indication that the client requires an increased protein diet based on the albumin level provided.
Choice C reason: The client's white blood cell (WBC) count is 1,400/mm³, which is below the normal range (normal: 4,500-11,000/mm³). This condition, known as leukopenia, significantly increases the risk of infection³. Therefore, the nurse should prioritize monitoring for signs of infection and implementing infection control measures.
Choice D reason: The client's platelet count is 170,000/mm³, which is within the normal range (normal: 150,000-450,000/mm³). Although cisplatin can cause thrombocytopenia, the current platelet count does not indicate an increased risk for bleeding⁴. Therefore, this choice is not correct based on the platelet count provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Bradycardia, which is a slower than normal heart rate, is not typically associated with diabetes insipidus. Diabetes insipidus primarily affects the kidneys and fluid balance in the body, leading to frequent urination and thirst but not directly affecting heart rate.
Choice B reason:
Moist mucous membranes are not expected in diabetes insipidus. In fact, due to excessive urination, a person with diabetes insipidus is more likely to experience dry mucous membranes from dehydration unless they are adequately hydrating.
Choice C reason:
Urine specific gravity 1.002 is a key finding in diabetes insipidus. This condition is characterized by the excretion of large amounts of dilute urine with low specific gravity. Normal urine specific gravity ranges from 1.005 to 1.030⁴. A value of 1.002 indicates very dilute urine, which is consistent with the inability of the kidneys to concentrate urine in diabetes insipidus.
Choice D reason:
Bounding peripheral pulses are not a finding associated with diabetes insipidus. Bounding pulses may be associated with other conditions such as fever, anemia, or hyperthyroidism but not typically with diabetes insipidus.
Correct Answer is B
Explanation
Choice A reason:
Applying a foot plate to the bed is not primarily intended to prevent pressure points from developing around the edges of the splint. A foot plate can help in maintaining proper alignment and preventing foot drop, but it does not address the issue of pressure points caused by the splint.
Choice B reason:
Repositioning the client is a key intervention to prevent pressure points. By changing the client's position regularly, the nurse can ensure that no single area is under prolonged pressure, which could lead to skin breakdown and pressure sores. This is particularly important in clients with limited mobility due to skeletal traction.
Choice C reason:
Removing the weights for a few minutes each hour is not a standard practice for preventing pressure points in balanced skeletal traction. The weights are integral to maintaining the necessary pull on the fractured femur, and their removal could disrupt the traction setup and potentially affect fracture healing.
Choice D reason:
Applying lotion to the skin under the edges of the splint is not recommended as it could soften the skin and make it more susceptible to injury. Instead, padding and proper positioning are used to protect the skin from the hard edges of the splint.
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