When planning care for a patient undergoing chemotherapy with neutropenia, which of the following precautions should be implemented?
Ensure all food is well-cooked and falls within neutropenic dietary guidelines.
Encourage the patient to wear a mask at all times at home and in public settings.
Perform frequent hand hygiene.
Instruct client to use an electric razor for shaving.
Limit visitors, especially those who are ill.
Keep the environment clean and free from potential sources of infection.
Allow fresh flowers and plants in the patient's room.
Correct Answer : A,C,E,F
Choice A rationale
Neutropenia occurs when the absolute neutrophil count drops below 1500 cells/microL, significantly increasing the risk of life-threatening infections. A neutropenic diet aims to eliminate exposure to raw or undercooked foods that may harbor pathogenic bacteria or fungi. Ensuring all food is well-cooked prevents the introduction of organisms like Listeria or Salmonella into the gastrointestinal tract, which can easily migrate into the bloodstream when the immune system is severely compromised.
Choice B rationale
While protective measures are necessary, requiring a patient to wear a mask at all times inside their own home is often unnecessary unless others present have active respiratory infections. The primary focus of neutropenic precautions is on hand hygiene and avoiding crowds rather than continuous masking in a controlled private environment. Excessive masking can also lead to skin irritation and decreased patient compliance. Environmental control and handwashing are more effective primary strategies for reducing infection risk.
Choice C rationale
Hand hygiene is the most effective intervention for preventing the transmission of healthcare-associated infections. For a neutropenic patient, the nurse and all caregivers must perform rigorous handwashing before and after every contact to remove transient flora. Because these patients lack sufficient white blood cells to mount an inflammatory response, preventing the colonization of the skin and mucous membranes is the first line of defense against opportunistic pathogens that could cause sepsis.
Choice D rationale
Using an electric razor is a standard precaution for patients with thrombocytopenia to prevent bleeding, rather than a primary precaution for neutropenia. While preventing skin breaks is important to avoid portals of entry for bacteria, the instruction to use an electric razor is specifically focused on the coagulation status. If the patient's platelet count is within the normal range of 150000 to 450000/mm, the risk of infection from a standard razor is relatively lower than the risk of bleeding.
Choice E rationale
Limiting visitors is a crucial step in reducing the patient's exposure to community-acquired viruses and bacteria. Individuals with even mild symptoms, such as a runny nose or cough, must be strictly excluded from the patient's environment. Because a neutropenic patient cannot effectively fight off common pathogens, a simple viral infection can quickly escalate into a systemic crisis. Controlling the number of people in the room minimizes the microbial load in the immediate vicinity.
Choice F rationale
Maintaining a clean environment involves the frequent disinfection of high-touch surfaces to eliminate reservoirs for bacteria like Pseudomonas or Staphylococcus. Stagnant water and dust should be removed, as they can harbor fungal spores and waterborne pathogens. A clean environment reduces the chance of environmental organisms colonizing the patient's skin or medical devices, such as intravenous catheters. This proactive approach is essential for protecting the vulnerable patient from exogenous sources of infection.
Choice G rationale
Fresh flowers and plants are strictly prohibited in the rooms of neutropenic patients because they are significant sources of mold and bacteria. Soil contains various fungi, such as Aspergillus, while the water in vases can become a breeding ground for gram-negative bacteria. If these spores or bacteria are inhaled or come into contact with the patient, they can cause severe respiratory or systemic infections that are difficult to treat due to the lack of neutrophils.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hypovolemic shock results from a significant decrease in intravascular volume, which is evidenced by the client's physical findings and vital signs. Poor skin turgor and dry mucous membranes indicate severe dehydration. The low blood pressure of 88/58 mmHg and tachycardia of 115/min are compensatory mechanisms for low cardiac output. The low urine output of 200 mL over 12 hours is well below the normal range of 30 mL/hour or 0.5 to 1.5 mL/kg/hour, confirming renal hypoperfusion.
Choice B rationale
Septic shock typically presents with signs of systemic infection, such as fever, which this client lacks with a temperature of 37.0 C. While hypotension and tachycardia occur in sepsis, the client specifically denies recent infections, making this less likely than simple volume depletion. Sepsis involves vasodilation and increased capillary permeability rather than the primary fluid loss suggested by the dry membranes and poor turgor. The lack of inflammatory markers or history of infection differentiates this from hypovolemia.
Choice C rationale
Hyperglycemic hyperosmolar state is characterized by extreme dehydration and very high blood glucose levels, usually exceeding 600 mg/dL. This client's glucose level is 81 mg/dL, which is within the normal fasting range of 70 to 99 mg/dL. While both conditions cause dehydration and lethargy, the absence of hyperglycemia completely rules out this metabolic complication of type 2 diabetes. The low blood pressure and high heart rate here are due to fluid loss rather than osmotic diuresis from sugar.
Choice D rationale
Acute urinary tract infection would typically present with symptoms such as dysuria, frequency, urgency, or cloudy urine. Systemic manifestations might include fever or flank pain. While the client has an indwelling catheter, which increases infection risk, the primary clinical picture is dominated by cardiovascular instability and severe volume depletion rather than localized or systemic infection. The low urine output of 16.7 mL/hour is a sign of prerenal failure due to hypovolemia rather than an obstructive or infectious process.
Correct Answer is C
Explanation
Choice A rationale
Metastasis is a defining characteristic of malignancy, not benignancy. Benign tumors remain localized to their site of origin and do not possess the genetic mutations or enzymatic capabilities, such as collagenase production, required to breach basement membranes and enter the lymphatic or circulatory systems. Scientifically, the absence of secondary tumor deposits in distant organs is a key diagnostic factor that clinicians use when reviewing pathology reports and imaging to determine the severity of a neoplasm.
Choice B rationale
Undifferentiated cells and high mitotic activity are classic markers of malignant transformation, known as anaplasia. Benign tumors generally consist of well-differentiated cells that closely resemble the parent tissue from which they arose. Their mitotic index is typically low, meaning cells divide at a rate similar to normal tissue. In contrast, malignant cells exhibit pleomorphism, large hyperchromatic nuclei, and frequent, often abnormal, mitotic figures, which signify a loss of cellular regulation and aggressive growth patterns.
Choice C rationale
Benign tumors are characterized by high levels of cellular differentiation and the presence of a fibrous capsule. This encapsulation prevents the tumor from infiltrating surrounding healthy tissues, creating a clear surgical plane that facilitates complete excision. Histologically, these cells maintain the functional and structural characteristics of the original tissue. This lack of invasiveness distinguishes them from malignant tumors, which grow by expansion and infiltration, often lacking a defined border and making surgical removal significantly more complex.
Choice D rationale
Benign tumors are typically slow-growing and do not usually lead to rapid clinical deterioration unless they are located in a critical area, such as the brain, where they might increase intracranial pressure. Aggressive growth and systemic wasting, or cachexia, are hallmarks of malignant processes. Malignant cells compete with healthy cells for nutrients and oxygen, often leading to significant metabolic shifts and the eventual failure of organ systems. Benign growths are generally considered non-threatening regarding immediate survival.
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