A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan?

Increase raw produce in the client's diet.

Limit visitors to healthy adults.

Instruct the client to floss his teeth daily.

Take the client's rectal temperature each day.

Answer and Explanation

The Correct Answer is B

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. A room with air exhaust directly to the outdoor environment. Clients with active tuberculosis (TB) require airborne precautions, which include placement in a negativepressure room with air exhaust directed outside to prevent the spread of infectious particles. This setup ensures that contaminated air does not circulate into other areas of the hospital.
B. A room in the ICU. The ICU is not an appropriate placement unless the client has severe respiratory distress or critical complications. TB patients should be isolated in a dedicated airborne infection isolation room (AIIR) rather than in an ICU, where other critically ill patients are at risk of exposure.
C. A room that is within view of the nurses' station. Proximity to the nurses' station is not a priority for TB management. Infection control measures, including negativepressure ventilation and airborne isolation, are far more important in reducing transmission risk.
D. A room with another nonsurgical client. TB is highly contagious, and placing the client in a shared room violates infection control protocols. Clients with active TB must be in a private, negativepressure room to prevent airborne transmission to others.

A. Avoid crowds. B. Take temperature weekly. C. Perform mild exercise, such as gardening. D. Eat plenty of fresh fruits and vegetables.

Correct Answer is A

Explanation

A. Avoid crowds. Clients with neutropenia have a significantly increased risk of infection due to a reduced neutrophil count, which impairs the immune response. Avoiding crowds helps minimize exposure to pathogens, reducing the risk of opportunistic infections. Clients should also practice hand hygiene, wear a mask in public places, and avoid close contact with sick individuals.
B. Take temperature weekly. Clients with neutropenia should monitor their temperature at least once daily, not weekly. A fever (≥100.4°F or 38°C) may be the only early sign of infection, which requires immediate medical attention due to the risk of sepsis.
C. Perform mild exercise, such as gardening. While mild exercise can promote overall wellbeing, gardening poses an infection risk due to exposure to soil, which may contain fungi, bacteria, and other pathogens (e.g., Aspergillus species). Clients should avoid activities that increase the risk of infection.
D. Eat plenty of fresh fruits and vegetables. Raw or unwashed fruits and vegetables can harbor bacteria and fungi, increasing infection risk. Clients with neutropenia should consume fully cooked foods, avoid raw produce, and follow proper food handling practices to prevent foodborne illnesses.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has active tuberculosis to a room on a medicalsurgical unit. Which of the following room assignments should the nurse make for the client?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

A nurse is caring for a school age child who has leukemia. Exhibits Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.

A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

A nurse is admitting a toddler who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

A nurse is caring for a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

A nurse is caring for a client. Exhibits Based on the information in the EHR, which of the following actions should the nurse take? Select all that apply.