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. Client describes a schedule for antacid use with other prescribed medications: While antacids might be part of the management plan, they do not address the underlying issue of rapid gastric emptying.
B. This is the most relevant outcome for a client who has developed post-Billroth II dumping syndrome, characterized by nausea, diarrhea, and diaphoresis after meals. Small, frequent meals with fluid intake between meals can help regulate blood sugar levels and reduce the rapid emptying of stomach contents into the small intestine, which is a primary cause of dumping syndrome.
C. Smoking can affect overall health but is not directly related to dumping syndrome.
D. Stress management is important for overall well-being but does not directly address the physiological changes causing dumping syndrome.

A. Surgical consent form is not signed. B. Client's pulse oximeter reading is 96%. C. Preoperative chest x-ray report is not available. D. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).

Correct Answer is D

Explanation

A. The surgical consent form is crucial for ensuring that the client is informed about the procedure and agrees to it. While it's critical for legal and ethical reasons, this issue can often be resolved relatively quickly by having the client sign the form or addressing it with the surgeon.
B. A pulse oximeter reading of 96% indicates that the client's oxygen saturation is within a generally acceptable range (normal is usually 95% to 100%). This reading suggests that the client's oxygen levels are adequate and typically would not require immediate action.
C. The absence of a preoperative chest x-ray report can be significant, especially if the client has underlying respiratory or cardiac conditions. However, the immediate need for action depends on the urgency and the reason the x-ray was ordered.
D. A serum potassium level of 2.8 mEq/L is critically low. The normal reference range is 3.5 to 5 mEq/L. Hypokalemia (low potassium) can lead to severe complications, including cardiac arrhythmias and muscle weakness, which can significantly impact the client's ability to safely undergo surgery. This condition requires immediate attention to correct the electrolyte imbalance before proceeding with the surgical procedure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

Correct Answer is B

Explanation

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

Correct Answer is D

Explanation

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