The nurse is providing care for a client with an absolute neutrophil count (ANC) of 400. Which action should the nurse perform prior to delivering the meal tray to the client's room?

Reference Range

Neutrophils (ANC) [Reference Range: 2500 to 8000 mm3 or 2500 to 8000 cells/uL]

Cut the spaghetti and meatballs into small pieces.

Exchange the pasteurized whole milk with skim milk.

Substitute the fried potatoes with a garden salad.

Remove the fresh grapes from the meal tray.

Answer and Explanation

The Correct Answer is D

Choice A

Cutting the spaghetti and meatballs into small pieces is inappropriate. This choice is not directly related to the risk of infection. It might be helpful for a client who has difficulty swallowing or chewing, but it doesn't address the compromised immune system and infection risk.

Choice B

Exchanging pasteurized whole milk with skim milk is inappropriate. The type of milk doesn't have a direct impact on infection risk. Both pasteurized whole milk and skim milk are considered safe for consumption. This choice doesn't address the specific concern of infection in a client with a low ANC.

Choice C

Substituting fried potatoes with a garden salad is inappropriate. While choosing healthier food options can be beneficial for overall health, the choice between fried potatoes and a garden salad doesn't necessarily impact the infection risk for a client with a low ANC. This choice also doesn't address the specific concern of infection in this context.

Choice D

Remove the fresh grapes from the meal tray is appropriate. The reason for this choice is that a client with an absolute neutrophil count (ANC) of 400 has a significantly compromised immune system, and they are at a high risk of infection due to their low neutrophil count. Neutrophils are a type of white blood cell that plays a crucial role in fighting off infections. A normal ANC falls within the range of 2500 to 8000 mm3 or cells/uL.

Fresh grapes, being a raw and uncooked food item, may carry a higher risk of containing bacteria or pathogens that could pose a threat to a client with such a low ANC. The nurse needs to ensure that the client's exposure to potential sources of infection is minimized.

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Correct Answer is A

Explanation

Choice A

Observing for abdominal distention is recommended. Gastric residual volume (GRV) is the amount of formula or food remaining in the stomach after a feeding through a gastric tube. A GRV of 325 mL is relatively high, and it's important to assess the client for signs of potential complications before contacting the healthcare provider. Observe for signs of abdominal distention, which could indicate that the stomach is not adequately emptying or that the feeding is not being tolerated well.

Choice B

Calculating 24-hour caloric intake is not recommended: While monitoring caloric intake is important for overall nutritional assessment, it does not address the immediate concern of a high GRV and the potential need for adjustment of the feeding rate or management.

Choice C

Measuring urinary output is not recommended: Urinary output is important to monitor for fluid balance, but it may not be directly related to the elevated GRV.

Choice D

Checking for body weight changes is not recommended: Monitoring body weight is essential for assessing nutritional status, but it may not provide immediate insights into the impact of the elevated GRV.

A. St. John's Wort B. Corticosteroids C. Ibuprofen D. Oral contraceptives E. Epinephrine

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale: St. John's Wort is an herbal supplement that can interact with various medications, including insulin, and may alter blood glucose levels. It can reduce the effectiveness of insulin, leading to decreased blood glucose control. It is essential for the client to inform the healthcare provider about any use of St. John's Wort to adjust the insulin regimen accordingly.

Choice B rationale: Corticosteroids can increase blood glucose levels by promoting insulin resistance and inhibiting insulin action. Clients with diabetes may require adjustments in their insulin dosage while taking corticosteroids to prevent hyperglycemia.

Choice Crationale: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that does not typically have a direct impact on blood glucose levels in people with diabetes.

Choice D: Oral contraceptives, specifically combination hormonal contraceptives containing estrogen and progestin, can impact blood glucose levels. They may lead to insulin resistance and, in some cases, increase blood glucose levels. The healthcare provider may need to adjust the insulin dosage for better glycemic control.

Choice E rationale: Epinephrine is a hormone that may transiently increase blood glucose levels in response to stress, but it is not a home medication that the client would be taking regularly.

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The nurse is providing care for a client with an absolute neutrophil count (ANC) of 400. Which action should the nurse perform prior to delivering the meal tray to the client's room? Reference Range Neutrophils (ANC) [Reference Range: 2500 to 8000 mm3 or 2500 to 8000 cells/uL]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving a continuous gastric tube feeding at 80 mL/hour. The nurse records the client's gastric residual volume as 325 mL during each of two consecutive hourly measurements. What assessment should the nurse complete before contacting the healthcare provider?

Correct Answer is A

Explanation

The nurse is preparing the client for discharge and discussing home medications. What home medications may affect the amount of insulin needed by the client? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

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The nurse is providing care for a client with an absolute neutrophil count (ANC) of 400. Which action should the nurse perform prior to delivering the meal tray to the client's room?

Reference Range

Neutrophils (ANC) [Reference Range: 2500 to 8000 mm3 or 2500 to 8000 cells/uL]