A nurse receives a report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?
Notify the primary health care provider and request antibiotics.
Inform the client that this signifies inflammation.
Document findings and continue monitoring.
Place the client in protective isolation.
The Correct Answer is A
Rationale for Choice A:
A shift to the left in the white blood cell (WBC) count indicates an increased presence of immature neutrophils, known as bands. This is a hallmark sign of infection, as the body is rapidly producing and releasing these cells to fight off invading pathogens.
Prompt notification of the primary health care provider is crucial to initiate timely antibiotic therapy, if indicated. Early intervention with appropriate antibiotics can effectively combat the infection, prevent its progression, and potentially avert serious complications.
Delaying antibiotic treatment can allow the infection to worsen, potentially leading to sepsis, septic shock, or other life- threatening conditions.
Rationale for Choice B:
While informing the client about the significance of a shift to the left is important for education and understanding, it does not address the immediate need for medical intervention.
The priority action is to involve the primary health care provider for prompt assessment and potential initiation of antibiotic therapy.
Rationale for Choice C:
Documenting findings and continuing to monitor the client's condition is essential for ongoing assessment and evaluation, but it does not constitute a proactive intervention to address the underlying infection.
Documentation alone does not initiate treatment, and monitoring without intervention risks allowing the infection to progress.
Rationale for Choice D:
Protective isolation is not routinely indicated for clients with a shift to the left in their WBC count unless there is a specific concern for transmission of a highly contagious infection.
The decision to implement protective isolation measures would be based on the client's overall clinical presentation and potential infectious risks, as determined by the primary health care provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Prednisone is a corticosteroid that suppresses the body's natural production of cortisol. Cortisol is a hormone that is essential for life, and it plays a role in many important bodily functions, including:
Regulating blood sugar levels Maintaining blood pressure Reducing inflammation Responding to stress
When a person takes prednisone for a long period of time, their body begins to rely on the medication to provide cortisol. If the medication is stopped suddenly, the body cannot produce enough cortisol on its own, which can lead to a life-threatening condition called adrenal insufficiency.
Adrenal insufficiency can cause a variety of symptoms, including: Extreme fatigue
Weakness Dizziness Nausea Vomiting Abdominal pain Confusion
Loss of consciousness
To prevent adrenal insufficiency, it is important to taper off prednisone slowly over a period of time. This allows the body to gradually adjust to producing cortisol on its own.
Here are some additional details about why prednisone should never be discontinued abruptly: The risk of adrenal insufficiency is highest when prednisone has been taken for more than 3 weeks. The longer a person has been taking prednisone, the slower the taper should be.
It is important to follow the tapering instructions provided by the healthcare provider.
If a person experiences any symptoms of adrenal insufficiency, they should seek medical attention immediately.
Correct Answer is B
Explanation
Choice B rationale:
Benign tumors typically grow in the wrong place or at the wrong time. This is a key distinguishing feature of benign tumors compared to normal cells. Normal cells have precise mechanisms that control their growth, ensuring they divide and multiply only when and where they are needed. Benign tumors, however, have disruptions in these regulatory mechanisms, leading to abnormal growth patterns. This means they may grow in locations where they don't belong or continue to grow even when they are no longer needed.
Here's a detailed explanation of why the other choices are incorrect:
Choice A:
Benign tumors have not lost their cellular regulation from contact inhibition. Contact inhibition is a process that stops normal cells from growing when they come into contact with other cells. Benign tumors still maintain this ability, which helps to limit their growth and prevent them from spreading to other tissues.
Choice C:
Benign tumors do not grow through invasion of other tissue. Invasion is a hallmark feature of malignant tumors (cancers). Benign tumors, on the other hand, typically grow as encapsulated masses, meaning they are surrounded by a well-defined border that separates them from surrounding tissues. They do not infiltrate or invade surrounding structures.
Choice D:
Anaplasia refers to the loss of differentiation and resemblance to the parent cells, which is a characteristic of malignant tumors, not benign tumors. Benign tumors still maintain a degree of differentiation, meaning they retain some of the characteristics of the normal cells from which they originated.
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