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.

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Correct Answer is ["B","C","D","E","F","G"]

Explanation

A. Hemoglobin: While the hemoglobin is at the lower end of normal, it is not critically low and does not require immediate reporting unless there is evidence of worsening anemia or active bleeding.
B. Upper respiratory infection: A persistent infection lasting over 2 months raises concern for relapsed leukemia or immunosuppression, especially given the elevated WBC count and persistent fever. This should be reported for further evaluation.
C. Breath sounds: The presence of clear breath sounds but with subcostal retractions suggests that the child is having difficulty breathing despite no significant lung congestion. This may indicate respiratory distress or worsening anemia, which requires immediate medical attention.
D. Skin assessment: Petechiae and unexplained bruising suggest thrombocytopenia, a common complication of leukemia relapse or bone marrow suppression. This could indicate a worsening condition and should be reported.
E. Retractions: Subcostal retractions are a sign of increased respiratory effort, suggesting that the child is struggling to maintain oxygenation. This is a serious finding that warrants immediate provider notification.
F. Oxygen saturation: A drop from 97% to 92% suggests respiratory compromise, which may be due to anemia, infection, or leukemic infiltration in the lungs. This decline needs to be reported promptly.
G. Respiratory rate: The increase from 22 to 30 breaths per minute indicates worsening respiratory distress, which may be due to anemia, infection, or respiratory failure. This change requires immediate attention.
H. WBC count: The elevated WBC count of 15,000/mm³ is above the normal range, which may indicate infection or possible leukemia relapse. However, since a mild elevation is expected with infection, it is not as immediately critical as the other findings.

A. Have the client refrain from talking for 24 hr. B. Suction the client's oropharynx frequently. C. Irrigate the client's throat every 4 hr. D. Withhold food and liquids until the client's gag reflex returns.

Correct Answer is D

Explanation

A. Have the client refrain from talking for 24 hr. While the throat may be sore after a bronchoscopy, complete voice rest for 24 hours is not necessary. The client may speak as tolerated once their gag reflex returns.
B. Suction the client’s oropharynx frequently. Routine oropharyngeal suctioning is not recommended unless the client has excessive secretions or airway obstruction. Unnecessary suctioning can cause irritation and discomfort.
C. Irrigate the client’s throat every 4 hr. Throat irrigation is not a standard postbronchoscopy intervention. Instead, throat lozenges or gargling with warm saline may help if the client experiences mild throat discomfort.
D. Withhold food and liquids until the client’s gag reflex returns. This is the most appropriate nursing action. A bronchoscopy involves the use of local anesthesia to numb the throat, which temporarily suppresses the gag reflex. To prevent aspiration, food and fluids should be withheld until the gag reflex has fully returned.

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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

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