The nurse is caring for a patient with lymphoma who is receiving chemotherapy.
The patient's laboratory results are below.
What interventions will the nurse implement related to these results? ANC (Absolute neutrophil count): 2400/mm³. Hemoglobin: 8.4 g/dL. Hematocrit: 25.9%. Platelets: 6,000/mm³.
Implement neutropenic precautions and administer broad-spectrum antibiotics.
Implement contact isolation precautions and administer intravenous prednisone.
Implement bleeding precautions and administer platelet transfusion.
Implement bedrest and administer packed red blood cell transfusion.
The Correct Answer is C
Choice A rationale
Neutropenic precautions and broad-spectrum antibiotics are indicated for patients with neutropenia to prevent infections. However, the patient's ANC is within the normal range (2400/mm³), so these measures are not necessary. This choice does not address the low hemoglobin and platelet count.
Choice B rationale
Contact isolation precautions and intravenous prednisone are not relevant to the patient's current condition. Prednisone is an immunosuppressive corticosteroid used for inflammatory and autoimmune conditions, but it does not address the patient's anemia or thrombocytopenia.
Choice C rationale
Bleeding precautions and platelet transfusion are appropriate interventions for the patient. The platelet count is critically low (6,000/mm³), putting the patient at high risk for spontaneous bleeding. Platelet transfusion is needed to increase platelet levels and reduce bleeding risk. Bleeding precautions, such as avoiding invasive procedures and using gentle oral care, help minimize the risk of hemorrhage.
Choice D rationale
Bedrest and packed red blood cell transfusion address the patient's anemia (hemoglobin 8.4 g/dL, hematocrit 25.9%). While these interventions are necessary to improve oxygen-carrying capacity, they do not address the critical issue of thrombocytopenia. Combining interventions C and D would be ideal for comprehensive care, but based on the question, Choice C is most critical for immediate bleeding risk management. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Estrogen replacement therapy can have various effects on the body but does not significantly impact thyroid diagnostic tests. This information is still relevant for the patient's overall medical care but not directly related to thyroid testing results.
Choice B rationale
Lactose sensitivity is important for dietary considerations but does not affect thyroid diagnostic tests. Documenting dietary restrictions is important for patient care but does not impact the specific diagnostic tests for thyroid function.
Choice C rationale
Anti-seizure medications can affect thyroid function tests, particularly those that affect the metabolism of thyroid hormones. However, the consumption of iodine-rich foods like kelp or seaweed has a more direct and significant impact on thyroid function and diagnostic testing.
Choice D rationale
Frequent consumption of kelp or seaweed, which are high in iodine, can influence thyroid function tests by altering thyroid hormone levels. This dietary habit should be documented and communicated to ensure accurate interpretation of thyroid function test results. .
Correct Answer is A
Explanation
Choice A rationale
Prevent graft versus host disease (GVHD) is a common complication following an allogeneic stem cell transplant. Immunosuppressant medications are given to prevent the donor immune cells from attacking the recipient's body tissues, which is GVHD. This prevention is crucial for the success of the transplant and the patient's overall recovery.
Choice B rationale
Prevent graft rejection is more commonly associated with solid organ transplants like kidney or liver transplants. In the context of stem cell transplants, preventing GVHD is the primary concern rather than preventing graft rejection.
Choice C rationale
Preventing hospital-acquired infections is important for all patients, especially those with compromised immune systems. However, this is not the primary indication for immunosuppressant medications following an allogeneic stem cell transplant. Other measures, such as infection control protocols, are more directly related to this.
Choice D rationale
Preventing a relapse of leukemia is a key goal of the overall treatment plan for leukemia patients. However, immunosuppressant medications do not directly prevent a relapse; instead, they help manage complications like GVHD that can arise from the transplant process.
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