The nurse includes the problem of "Risk for infection" in the plan of care for a client with myelosuppression. Which laboratory value of care provides the greatest support for this nursing problem?

Reference Range

Hemoglobin (Hgb) (14 to 18 g/dL (8.69 to 11.17 mmol/L] Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)]

Red Blood Cell Count (RBC) [4.2 to 5.4 x 10/μL (4.2 to 5.4 x 1012/L)] White Blood Cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 10"/L)]

Hematocrit of 33% (0.33 volume fraction).

White blood cell count of 1,500/mm3 (1.5 x 10°)

Hemoglobin of 10 g/dl (6.21 mmol/L)

Red blood cell count of 3.5 x 10l(3.5 x 10").

Answer and Explanation

The Correct Answer is B

A.   Hematocrit measures the proportion of blood volume that is occupied by red blood cells. A hematocrit of 33% is lower than the normal range (42% to 52% for males and 37% to 47% for females). While this indicates anemia and reduced oxygen-carrying capacity of the blood, it is not directly related to the risk for infection.
B.   White blood cells (WBCs) are crucial for the immune system and fighting infections. A WBC count of 1,500/mm³ is significantly below the normal range (5,000 to 10,000/mm³). This low WBC count, also known as leukopenia, indicates a decreased ability to fight infections, making the client highly susceptible to infections.
C.   Hemoglobin measures the oxygen-carrying capacity of red blood cells. A hemoglobin level of 10 g/dL is below the normal range (14 to 18 g/dL), indicating anemia. While anemia affects overall health and can contribute to fatigue and weakness, it does not directly indicate the risk for infection.
D.   The red blood cell (RBC) count measures the number of red blood cells in the blood. A count of 3.5 x 10^12/L is below the normal range (4.2 to 5.4 x 10^12/L), indicating a reduction in red blood cells and anemia. Like low hemoglobin, this value indicates anemia but does not directly reflect the risk for infection.

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Free Nursing Study Resources

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

Explanation

A. Vomiting is not a common side effect of phenytoin but could occur in some patients. It’s more likely a
reaction to the medication rather than a frequent side effect.
B. Phenytoin can affect blood coagulation. It may interfere with vitamin K metabolism, which can alter coagulation pathways and increase the risk of bleeding or bruising. Monitoring for signs of bleeding or changes in clotting status is important, particularly in patients on long-term therapy.
C. Visual disturbances, including nystagmus (involuntary eye movements), double vision, or blurred vision, can occur with phenytoin use. This side effect is related to the medication’s impact on the nervous system.
D. Drowsiness is a common side effect of many antiepileptic drugs, including phenytoin. It can affect the client’s alertness and overall level of consciousness, making it important for the nurse to monitor and address any related safety concerns.
E. Aphasia, or difficulty with language and speech, is not a typical side effect of phenytoin. While phenytoin affects the central nervous system, aphasia is not commonly reported with its use.
F. Ataxia, or lack of coordination and unsteady movements, is a known side effect of phenytoin. This occurs due to its effects on the nervous system and can impair motor skills and coordination.

A. Discard the incorrectly dialed dose and recalibrate the insulin pen. B. Save the dialed dose and prepare the correct dose using a syringe C. Assist the client to administer 24 units of the dialed dose, and waste the remainder. D. Advise the client to dial down to the correct dose, which can then be administered.

Correct Answer is A

Explanation

A. Administering an incorrect dose of insulin can lead to hypoglycemia, a serious complication. Discarding the incorrectly dialed dose ensures patient safety. Directly addresses the error and prevents potential harm.
B. This option is inefficient and increases the risk of error. It's unnecessary to use both a pen and a syringe for a single dose. Does not address the immediate issue of the incorrect dose.
C. Administering more insulin than prescribed is dangerous and can lead to hypoglycemia. Wasting the remainder doesn't address the core issue of the incorrect dose. Increases the risk of hypoglycemia.
D. Insulin pens are designed to be precise. Dialing down to the correct dose after an error can compromise the accuracy of the dose. Does not ensure accurate dosing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.

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

Explanation

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

Correct Answer is A

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

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The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?

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