The patient has agranulocytosis with a neutrophil count of 10%. The most important nursing intervention would be
a. restoring fluid volume deficit.
b. providing oxygen per mask.
c. instituting bleeding precautions.
d. avoiding infection.
D
Nursing interventions are directed toward protecting the patient from potential sources of infection. Neutrophils ingest bacteria and dispose of dead tissue. They are the primary phagocytic cells involved in acute inflammatory response.
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The student nurse is learning how to reduce the stigma associated with mental illness. Which of the following statements by the student nurse reflects that learning has taken place?
1. "We're admitting another schizophrenic who hears God talking." 2. "A 19-year-old who reports hearing voices is being admitted with a diagnosis of psychosis not otherwise specified." 3. "We're admitting another crazy client." 4. "They've added another paranoid to the unit."
After the nurse describes fetal circulation to a pregnant woman, the woman asks why her fetus has a different circulation pattern than hers. In planning a response, the nurse is guided by the principle that:
A) Fetal blood is thicker than that of adults and needs different pathways B) Fetal circulation carries highly oxygenated blood to vital areas first C) Fetal blood has a higher oxygen saturation and circulates slower D) Fetal heart rates are rapid and circulation time is double that of adults
While a mother is feeding her high-risk neonate, the nurse observes the neonate having occasional apnea, pallor, and bradycardia. What is the most appropriate nursing action?
a. Let the neonate rest before breastfeeding again. b. Resume gavage feedings until the neonate is asymptomatic. c. Recognize that this may indicate an underlying illness. d. Use a high-flow, pliable nipple because it requires less energy to use.
The nurse is reviewing new medication orders for a patient who has an epidural catheter for pain relief. One of the orders is for enoxaparin (lovenox), a low- molecular weight heparin (LMWH). What is the nurse's priority action?