RN Nursing · Immune Assessment · Practice question
A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?
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Use clean techniques for invasive procedures.
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Make sure the client's room is cleaned every 2 days.
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Allow healthy children to visit.
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✓
Monitor the client's temperature every 4 hr.
Answer & explanation
Correct: Monitor the client's temperature every 4 hr.
Neutropenia is a dangerously low neutrophil count that severely impairs the client's ability to fight infection. Because neutropenic clients lack the normal inflammatory response, they may not produce the classic signs of infection; fever may be the earliest and sometimes the only detectable indicator. Monitoring temperature every 4 hours allows the nurse to detect a fever promptly so that blood cultures can be obtained and broad-spectrum antibiotic therapy can be initiated before a life-threatening septic process develops. Using clean rather than sterile technique for invasive procedures is incorrect and dangerous; strict sterile technique must be used to minimize the introduction of pathogens in an immunocompromised client. Cleaning the room every 2 days is inadequate; a neutropenic environment should be maintained with daily cleaning and, ideally, specialized air filtration. Allowing healthy children to visit is risky because children are common vectors for community-acquired viruses and other pathogens that could be lethal to a neutropenic client. Children, particularly those who may have been recently vaccinated with live-virus vaccines, should generally be restricted from visiting. Consistent temperature monitoring is the most appropriate and actionable instruction among the options provided.
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