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71.ID: 327495367A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3. Which of the following interventions does the nurse implement on the basis of this finding? Select all that apply.A. Providing a soft toothbrush for oral careB. Monitoring the client’s oral temperatureCorrectC. Maintaining sterile occlusion of intravenous (IV) catheters CorrectD. Requiring the client to use an electric shaver rather than a razorE. Performing meticulous skin decontamination before venipuncture CorrectF. Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure
Rationale: When the neutrophil count falls below 500 cells/mm3, the client is at risk for infection. Monitoring of the oral temperature, maintaining sterile occlusion of IV and central venous catheters, and meticulous skin decontamination before venipuncture are critical nursing interventions for the client at risk for infection. The remaining options are interventions that are necessary for the client who has a low platelet count and is at risk for bleeding.Test-Taking Strategy: Focus on the information in the question and note that the client’s neutrophil count is low. Recalling the relationship between a low neutrophil count and the risk for infection will direct you to the correct options. If you had difficulty with this question, review the nursing plan of care for a client with leukemia who has a low neutrophil count.Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positiveoutcomes (8th ed., pp. 2121. 2122). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Infection ControlAwarded 1.0 points out of 1.0 possible points.BP.72.ID: 327495359A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is especially important?A. The religious affiliation or church of preferenceB. The names of close friends and family membersCorrectC. What medications have been prescribed and what the client knows about their side effectsD. The name of the person from whom the client contracted TB, so that the person may be reported for follow-up careRationale: TB is a contagious disease that is spread in respiratory droplets. The nurse needs to elicitthe names of close friends and family members so that these individuals may be tested for exposureto TB. The client’s religious affiliation or church of preference is a component of the data collection process but is not the primary consideration of the options provided. It is premature to determine knowledge regarding medications, because treatment measures may not yet have been prescribed. The client may not know the name of the person from whom the disease was contracted.
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Nursing, Potter, content area, cognitive ability, Care Environment