Editing Medical-Surgical Nursing – RN Practice Questions (section)

==Question 12==
A patient receiving chemotherapy has an absolute neutrophil count of 380 cells per microliter. Which interventions should the nurse implement? '''Select all that apply.'''
# Report a temperature of 100.5 degrees Fahrenheit to the provider promptly.
# Remove fresh flowers and standing water from the patient's room.
# Take the temperature rectally every four hours for accuracy.
# Screen all visitors for signs of respiratory or gastrointestinal illness.
# Perform meticulous hand hygiene before all patient contact.

'''Answer:''' Options 1, 2, 4, and 5.

''Rationale:'' With severe neutropenia the inflammatory response is blunted, so even a low-grade fever may be the only sign of serious infection and is treated as an emergency. Fresh flowers and standing water harbor organisms, visitor screening reduces exposure, and hand hygiene is the single most effective preventive measure. Option 3 is contraindicated, because rectal temperatures, suppositories, and enemas can cause mucosal trauma and introduce bacteria into the bloodstream in a neutropenic patient.