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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Correct Answer is B

Explanation

A. Increasing oxygen flow might seem like an immediate response, but it's crucial to be cautious with oxygen therapy in COPD patients. They often have a chronic CO2 retention issue, and excessive oxygen can sometimes reduce their drive to breathe, potentially worsening their condition. The increase in oxygen should be based on specific clinical guidelines and patient response, rather than an automatic increase.
B. Obtaining a stat arterial blood gas (ABG) is an important diagnostic step to evaluate the client’s oxygenation, ventilation, and acid-base status. This can provide critical information on the severity of the dyspnea and guide further treatment. It’s an essential action, particularly in acute dyspnea, as it helps in understanding the underlying cause and tailoring appropriate interventions.
C. The client is already in a high-Fowler’s position, which is optimal for improving lung expansion and easing dyspnea. Lowering the bed to a semi-Fowler’s position might not provide additional relief and could potentially worsen the client’s dyspnea. High-Fowler's position is generally preferred for severe dyspnea as it maximizes lung expansion and facilitates breathing.
D. Pursed-lip breathing is a helpful technique for managing dyspnea in COPD patients. It helps to prolong exhalation, reduce airway collapse, and improve gas exchange. This technique can provide immediate relief by helping the client control their breathing and reduce feelings of breathlessness.

A. Stone fragments are collected when straining the client's urine. B. Client denies urinary frequency, urgency, or dysuria. C. Urine is pale pink with no observable blood clots. D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

Correct Answer is A

Explanation

A. This directly indicates that the lithotripsy procedure was successful in breaking down the stone into smaller fragments that can be passed through the urinary tract.
B. While the absence of these symptoms is a positive sign, it does not directly confirm the success of the lithotripsy procedure. These symptoms can be present even if the stone has been broken down.
C. Pale pink urine is expected after lithotripsy due to minor bleeding. The absence of blood clots is also a good sign, but it doesn't definitively confirm the procedure's success.
D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits. These lab values are important indicators of kidney function but do not directly relate to the success of the lithotripsy procedure itself.

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Naxlex Comprehensive Predictor Exams

A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

Correct Answer is B

Explanation

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Correct Answer is A

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