A nurse is reviewing hematology laboratory results of a client receiving intravenous chemotherapy for leukemia. Which of the following laboratory findings prompts the nurse to initiate neutropenic precautions?

A white blood cell count of 1000/mm3

A red blood cell count of 5 million/mm3

A clotting time of 10 minutes

A thrombocyte count of 90,000 cells/mm3

Answer and Explanation

The Correct Answer is A

Choice A reason: This is correct. A white blood cell count of 1000/mm3 indicates severe neutropenia, which is a condition of having abnormally low levels of neutrophils, a type of white blood cell that fights infections. Neutropenic precautions are measures to protect the client from exposure to pathogens, such as wearing a mask, gloves, and gown, avoiding contact with sick people, and practicing good hygiene.

Choice B reason: This is incorrect. A red blood cell count of 5 million/mm3 is within the normal range for both males and females. It does not indicate any risk of infection or bleeding.

Choice C reason: This is incorrect. A clotting time of 10 minutes is also within the normal range, which is 8 to 15 minutes. It does not indicate any risk of infection or bleeding.

Choice D reason: This is incorrect. A thrombocyte count of 90,000 cells/mm3 is low, but not low enough to require neutropenic precautions. Thrombocytes, also known as platelets, are responsible for blood clotting. A low thrombocyte count increases the risk of bleeding, but not infection. The normal range for thrombocyte count is 150,000 to 450,000 cells/mm3.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. The foot remaining in the same position prior to stroking the sole of the foot is a normal response in adults. It indicates that the spinal cord and the brain are intact and functioning properly.

Choice B reason: This is correct. Great toe bending upward, and smaller toes fanning outward is an abnormal response in adults. It indicates a positive Babinski reflex, which is a sign of damage to the cerebral cortex or the pyramidal tract. The cerebral cortex is the outer layer of the brain that controls higher functions such as thinking, reasoning, and movement. The pyramidal tract is a bundle of nerve fibers that connects the cerebral cortex to the spinal cord and controls voluntary movements.

Choice C reason: This is incorrect. Great toe bending downward is also a normal response in adults. It indicates that the spinal cord and the brain are intact and functioning properly.

Choice D reason: This is incorrect. The opposite foot assuming the same position as the foot being stroked is not related to the Babinski reflex. It is a phenomenon called mirror movement, which may occur in some people due to genetic or developmental factors. It does not indicate any abnormality in the cerebral cortex.

A. Administer a dose of a prescribed antiepileptic drug and position the person supine. B. Wrap the patient in warm blankets and hyperextend their neck. C. Offer the patient a crossword to work on to promote mental stimulation. D. Establish that the patient has a patent airway after the seizure ends and assess for breathing.

Correct Answer is D

Explanation

Choice A reason: This is incorrect. Administering a dose of a prescribed antiepileptic drug is an appropriate intervention, but it should be done during the seizure, not after. Positioning the person supine is also not recommended, as it can compromise the airway and increase the risk of aspiration.

Choice B reason: This is incorrect. Wrapping the patient in warm blankets and hyperextending their neck are both harmful actions, as they can increase the body temperature and obstruct the airway. The patient should be kept cool and comfortable, and their head should be tilted to the side or supported with a pillow.

Choice C reason: This is incorrect. Offering the patient a crossword to work on to promote mental stimulation is not an essential intervention, and it may not be feasible or appropriate for a patient who has just experienced a prolonged seizure. The patient may need rest and observation, not cognitive tasks.

Choice D reason: This is correct. Establishing that the patient has a patent airway after the seizure ends and assessing for breathing are the most important interventions, as they ensure the oxygenation and ventilation of the patient. The nurse should also monitor the vital signs, neurological status, and blood glucose levels of the patient.

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A nurse is reviewing hematology laboratory results of a client receiving intravenous chemotherapy for leukemia. Which of the following laboratory findings prompts the nurse to initiate neutropenic precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse evaluates the Babinski reflex and strokes the sole of the patient's foot from the outer heel to the little toe. The patient was in an automobile accident and has a decreased level of consciousness. Which response indicates an abnormality in the cerebral cortex?

Correct Answer is B

Explanation

The nurse should complete which essential interventions for a patient who has experienced status epilepticus?

Correct Answer is D

Explanation

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