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. The client has hypertension and anuria B. The client develops bradycardia and bradypnea C. The client has hypotension and is confused D. The client has metabolic alkalosis and warm extremities

Correct Answer is C

Explanation

A. The client has hypertension and anuria. Hypertension is not a common feature of postoperative shock. Instead, shock is typically characterized by hypotension due to inadequate perfusion. Anuria, while concerning, is usually a later sign of severe hypovolemia or organ failure rather than an early indicator of shock.
B. The client develops bradycardia and bradypnea. Shock generally triggers a compensatory response, leading to tachycardia as the body attempts to maintain cardiac output. Bradycardia and bradypnea are more commonly associated with conditions such as neurogenic shock or opioid overdose rather than hypovolemic or septic shock, which are more frequent in postoperative settings.
C. The client has hypotension and is confused. Hypotension is a hallmark sign of postoperative shock, often resulting from blood loss, fluid shifts, or sepsis. Confusion occurs due to decreased cerebral perfusion and oxygenation. These symptoms indicate a state of inadequate circulation requiring immediate intervention, making this the most appropriate answer.
D. The client has metabolic alkalosis and warm extremities. Postoperative shock is more commonly associated with metabolic acidosis due to poor tissue perfusion and lactic acid buildup rather than alkalosis. Additionally, warm extremities are typical in early septic shock, whereas most types of shock, such as hypovolemic or cardiogenic shock, lead to cool, clammy skin due to vasoconstriction.

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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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Explanation

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Correct Answer is C

Explanation

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