Which strategy is most important for a nurse to include when planning care for a patient who has neutropenia?

Choice A rationale:

Dizziness with a blood pressure of 150/92 mm Hg indicates hypertension, but it is not an immediate life-threatening condition requiring urgent assessment compared to a severe headache and vomiting.

Choice B rationale:

A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.

Choice C rationale:

A hip fracture with a pain level of 2 on a 1-to-10 scale suggests pain but is not immediately life-threatening compared to symptoms like severe headache and vomiting.

Choice D rationale:

Fatigue after receiving an ACE inhibitor is a common side effect and, while important to monitor, does not pose an immediate threat compared to the symptoms of severe headache and vomiting.

Choice A rationale:

Restricting all visitors might be beneficial in preventing infections, but it is not the most important strategy for a patient with neutropenia. The main concern is the risk of infections due to the compromised immune system.

Choice B rationale:

Placing the patient in a private room is crucial for a neutropenic patient. Neutropenia, characterized by a low absolute neutrophil count (ANC), significantly compromises the patient's immune system, making them highly susceptible to infections. Isolating the patient helps minimize the risk of exposure to pathogens, reducing the likelihood of infections.

Choice C rationale:

Using an electric shaver instead of a razor is advisable to prevent cuts and minimize the risk of skin infections. While this is a good practice, it is not the most important strategy compared to isolating the patient and using personal protective equipment (PPE) during direct patient care.

Choice D rationale:

Wearing a gown and gloves when in direct contact with the patient is essential to prevent the spread of infections. This is a necessary measure, but isolating the patient in a private room takes precedence as it minimizes the risk of exposure to pathogens, providing a safer environment for the neutropenic patient.