Nokea
A patient's absolute neutrophil count (ANC) is 440/mm3. But the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient?
- A. Meticulous hand hygiene
- B. Timely administration of antibiotics
- C. Provision of a nutrient-dense diet
- D. Maintaining a sterile care environment
Correct Answer: A
Rationale: Providing care for a patient with neutropenia requires that the nurse adhere closely to standard precautions and infection control procedures. Hand hygiene is central to such efforts. Prophylactic antibiotics are rarely used and it is not possible to provide a sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central aspect of care.
You may also like to solve these questions
A patient with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurse's assessment questions relates most directly to this patient's hematologic disorder?
- A. When did you last have a blood transfusion?
- B. What medications have taken recently?
- C. Have you been under significant stress lately?
- D. Have you suffered any recent injuries?
Correct Answer: B
Rationale: Exacerbations of glucose-6-phosphate dehydrogenase deficiency are nearly always precipitated by medications. Blood transfusions, stress, and injury are less common triggers.
The medical nurse is aware that patients with sickle cell anemia benefit from understanding what situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to prevent crises, what measures should the nurse recommend?
- A. Using prophylactic antibiotics and performing meticulous hygiene
- B. Maximizing physical activity and taking OTC iron supplements
- C. Limiting psychosocial stress and eating a high-protein diet
- D. Avoiding cold temperatures and ensuring sufficient hydration
Correct Answer: D
Rationale: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic.
A patient is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals an oral temperature of 100.5°F and a new onset of fine crackles on lung auscultation. What is the nurse's most appropriate action?
- A. Apply supplementary oxygen by nasal cannula.
- B. Administer bronchodilators by nebulizer.
- C. Liaise with the respiratory therapist and consider high-flow oxygen.
- D. Inform the primary care provider that the patient may have an infection.
Correct Answer: D
Rationale: Patients with sickle cell disease are highly susceptible to infection; thus any early signs of infection should be reported promptly. There is no evidence of respiratory distress, so oxygen therapy and bronchodilators are not indicated.
A patient's low prothrombin time (PT) was attributed to a vitamin K deficiency and the patient's PT normalized after administration of vitamin K. When performing discharge education in an effort to prevent recurrence, what should the nurse emphasize?
- A. The need for adequate nutrition
- B. The need to avoid NSAIDs
- C. The need for constant access to factor concentrate
- D. The need for meticulous hygiene
Correct Answer: A
Rationale: Vitamin K deficiency is often the result of a nutritional deficit. NSAIDs do not influence vitamin K synthesis and clotting factors are not necessary to treat or prevent a vitamin K deficiency. Hygiene is not related to the onset or prevention of vitamin K deficiency.
A nurse is caring for a patient with severe anemia. The patient is tachycardic and complains of dizziness and exertional dyspnea. The nurse knows that in an effort to deliver more blood to hypoxic tissue, the workload on the heart is increased. What signs and symptoms might develop if this patient goes into heart failure?
- A. Peripheral edema
- B. Nausea and vomiting
- C. Migraine
- D. Fever
Correct Answer: A
Rationale: Cardiac status must be carefully assessed in patients with anemia. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly), and by peripheral edema. Nausea, migraine, and fever are not associated with heart failure.