Question

A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1000/mm��. Which of the following interventions should the nurse include in the plan?

a. Take the client's rectal temperature each day
b. Increase raw procedure in the client's diet
c. Limit visitors to healthy adults
d. Instruct the client to floss his teeth daily

Answer 1

For a client with an ANC less than 1000/mm³, the nurse should include limiting visitors to healthy adults in the care plan to reduce infection risk and avoid rectal temperature measurements and flossing that can cause mucosal damage.

Step-by-step explanation:

The subject of this question is Medicine, specifically pertaining to nursing care for a client with a compromised immune system indicated by a low absolute neutrophil count (ANC). The nurse should include in the care plan measures to reduce the risk of infection due to the client's neutropenia. Such measures include:

• Limiting visitors to healthy adults to reduce the risk of exposing the client to potential infections.
• Avoiding procedures that could cause mucosal damage, such as rectal temperature measurements, as these can introduce pathogens.
• Encouraging the client about the importance of maintaining good oral hygiene while avoiding activities that could lead to gum injury, such as flossing if it causes bleeding.

Increasing raw produce in the client's diet and instructing the client to floss his teeth daily would not be appropriate due to the increased risk of infection from bacteria in raw foods and the potential for gum injury from flossing, respectively.