41. A week after chemotherapy, a client's absolute neutrophil count (ANC) is 300/mm3.
Which nursing interventions are appropriate? Select all that apply.
41. A week after chemotherapy, a client's absolute neutrophil count (ANC) is 300/mm3.
Which nursing interventions are appropriate? Select all that apply.
. Apply gloves while hands are still damp from washing.
. Use an alcohol-based hand wash.
. Remove fresh flowers from the room.
. Triple-wash all fresh vegetables.
. Avoid fresh unpeeled fruits.
. Place in same room with another client who is free of airborne infections.
Test-Taking Tip
Think of actions that reduce the risk of infection. Choose the four options that are precautionary (e.g., wash hands and fresh vegetables; remove flowers; avoid unpeeled fruit).
Content Area: Adult Health, Hematological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Standard/Transmission-based/Other Precautions
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Answer 1 is incorrect because hands should be dry before applying gloves, which are difficult to put on with wet hands. Microorganisms survive better in moist environments. Answer 2 is correct because this client has few white blood cells (WBCs), and must be protected from infection. Neutrophils make up 55% to 70% of WBCs. An ANC below 1,000/mm3 places the client at significant risk for infection. Alcohol-based hand cleaners that are at least 60% alcohol eliminate microbes as well as soap and water. Answer 3 is correct because this client has few white blood cells, and must be protected from infection. An ANC below 1,000/mm3 places the client at high risk for infection. Fresh flowers contain many microbes. Answer 4 is incorrect because this client has few white blood cells, and must be protected from infection. The risk for infection increases as the ANC decreases. Vegetables should be washed and cooked. Triple-washing is not necessary. Answer 5 is correct because this client has few white blood cells, and must be protected from infection. A normal ANC would be 2,000/mm3 or higher. Most microbes are on the outer surface of the fruit. Fruit must be peeled or cooked. Answer 6 is incorrect because this client has few white cells and must be protected from all sources of infections.