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NCLEX · Reduction of Risk Potential

A nurse is caring for a client receiving chemotherapy who develops neutropenia (low neutrophil count). What is the priority nursing intervention?

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Correct answer

Implement neutropenic precautions to protect the client from infection (strict hand hygiene, avoid crowds/sick people, no fresh flowers/raw produce per policy)

  1. A Restrict fluids
  2. B Stop monitoring temperature
  3. C Encourage visitors freely
  4. D Implement neutropenic precautions to protect the client from infection (strict hand hygiene, avoid crowds/sick people, no fresh flowers/raw produce per policy)

Why this is the answer

NEUTROPENIA (abnormally low neutrophils, often from chemotherapy) severely weakens the immune system, making INFECTION the major life-threatening risk. The priority is NEUTROPENIC PRECAUTIONS (protective/reverse isolation) to protect the client: strict HAND HYGIENE; avoid crowds and people who are sick; private room (per policy); avoid raw/undercooked foods, fresh flowers, and standing water (sources of organisms); no live plants; meticulous skin/oral care; monitor TEMPERATURE closely. NCLEX physiological/oncology. A FEVER in a neutropenic client is a medical emergency (neutropenic fever/sepsis) — report immediately, as the client may not show typical infection signs (few neutrophils to produce pus/inflammation). Protecting the neutropenic client from infection is a heavily tested NCLEX oncology concept.
Source: NCLEX Physiological — Neutropenic Precautions

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About this topic: Reduction of Risk Potential

Reduction of risk potential questions cover recognising changes in condition, interpreting labs and diagnostics, pre- and post-procedure care, and preventing complications before they develop. This is one of 6 RN: Physiological Integrity questions on reduction of risk potential, each with a full explanation on a single study page.

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