# Situation: A 34-year-old man is admitted with newly diagnosed acute myeloid leukemia (AML). His white blood cell count is 45,000/mm³ with 70% blasts, his hemoglobin is 8.2 g/dL (82 g/L), and his platelet count is 15,000/mm³. Induction chemotherapy is planned. During neutropenia, he asks which foods are safe to eat. Which choice should the nurse approve?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629833  
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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 34-year-old man is admitted with newly diagnosed acute myeloid leukemia (AML). His white blood cell count is 45,000/mm³ with 70% blasts, his hemoglobin is 8.2 g/dL (82 g/L), and his platelet count is 15,000/mm³. Induction chemotherapy is planned.

During neutropenia, he asks which foods are safe to eat. Which choice should the nurse approve?

## 보기

1. Eggs with a runny yolk
2. Well-washed fresh fruit **✔ 정답**
3. Rare grilled beef steak
4. Unpasteurized fresh milk

**정답: 2**

## 해설

Safe food handling protects neutropenic clients: produce is washed well, meat and eggs are cooked thoroughly, and unpasteurized products are avoided. Strict neutropenic diets that ban all fresh fruit have not shown benefit.

## 심화 해설

Clinical Context

Acute myeloid leukemia (AML) at diagnosis often presents with circulating blasts and profound pancytopenia. Induction chemotherapy then produces a period of severe neutropenia during which the absolute neutrophil count falls low enough that the patient loses the first-line defense against ingested and colonizing microbes. The gastrointestinal tract becomes both a potential portal of entry and a reservoir for organisms that can translocate when mucosal integrity is compromised by cytotoxic therapy [1][4].

The question asks which food choice is safe, not which diet is most restrictive. The correct answer reflects a shift from the traditional neutropenic diet toward a food safety-based approach, in which the goal is reducing microbial contamination through proper handling, washing, and cooking rather than banning entire food categories [3][4].

Well-washed fresh fruit is acceptable because thorough washing mechanically removes surface pathogens without eliminating the nutritional benefit of fresh produce. The evidence does not demonstrate that strict bans on all fresh fruits reduce infection rates, and such restrictions may impair caloric intake and quality of life [1][2][3].

Key point! The distinction is not raw versus cooked alone; it is whether the food has been handled and prepared in a way that minimizes bacterial load.

| Food choice | Safety concern | Why it is rejected or allowed |
| --- | --- | --- |
| Eggs with a runny yolk | Undercooked egg; risk of Salmonella | Eggs must be cooked until both white and yolk are firm to destroy pathogens [4] |
| Well-washed fresh fruit | Surface contamination only | Allowed when washed thoroughly; no proven benefit to banning all fresh fruit [1][3] |
| Rare grilled beef steak | Undercooked meat; risk of E. coli, Salmonella, Campylobacter | Meat must be cooked to a safe internal temperature; rare or undercooked meat is not permitted [4] |
| Unpasteurized fresh milk | Unpasteurized dairy; risk of Listeria, Brucella, Campylobacter | Only pasteurized dairy products are considered safe during neutropenia [4] |

The underlying principle is that neutropenic precautions should focus on safe food handling rather than arbitrary food prohibition. A randomized noninferiority trial in patients undergoing hematopoietic stem-cell transplantation or induction chemotherapy for acute leukemia found that a liberalized diet emphasizing food safety did not result in a higher rate of major infections compared with a traditional neutropenic diet [1]. Similarly, a pediatric before-and-after study showed that moving to a food safety-based diet did not increase infection risk while reducing unnecessary dietary restrictions [2].

Watch out! A common exam trap is to assume that all fresh produce is forbidden during neutropenia. The evidence-based approach allows fresh fruit and vegetables if they are washed well; what is prohibited is undercooked meat, runny eggs, and unpasteurized dairy products [3][4].

The clinical practice guideline developed by a multinational panel specifically recommends against the routine use of food restrictions to prevent infections in pediatric oncology and hematopoietic cell transplantation patients, instead endorsing safe food handling practices [3]. This recommendation aligns with the correct answer: the nurse should approve the well-washed fresh fruit, while teaching the patient to avoid undercooked animal products and unpasteurized dairy.References (research sources)

- [1]Randomized Noninferiority Trial of a Liberalized Diet Versus the Neutropenic Diet in Hematopoietic Stem-Cell Transplant Patients and Patients With Acute Leukemia.RCT/clinical trialWingard JR, Lee JH, Li D, Al-Mansour Z, Farhadfar N, Hsu J (2026) · DOI: 10.1200/JCO-25-00889

- [2]Comparing a Neutropenic Diet to a Food Safety-Based Diet in Pediatric Patients Undergoing Hematopoietic Stem Cell Transplantation.Research articleTaggart C, Neumann N, Alonso PB, Lane A, Pate A, Stegman A (2019) · DOI: 10.1016/j.bbmt.2019.03.017

- [3]Use of food restrictions to prevent infections in paediatric patients with cancer and haematopoietic cell transplantation recipients: a systematic review and clinical practice guideline.GuidelinePhillips R, Fisher BT, Ladas EJ, Patel P, Robinson PD, Dupuis LL (2025) · DOI: 10.1016/j.eclinm.2025.103093

- [4]The neutropenic diet reviewed: moving toward a safe food handling approach.Research articleFox N, Freifeld AG (2012)

## 임상 시나리오

Neutropenic Food SafetySafe choices during chemotherapy-induced neutropenia
A food safety-based approach is preferred over a strict neutropenic diet. Fresh produce is acceptable when washed thoroughly to remove surface pathogens.

All meat and eggs must be cooked thoroughly. Avoid runny yolks and rare beef because undercooked items may carry Salmonella or other bacteria.

Unpasteurized milk and dairy products are unsafe and should be avoided because of the risk of Listeria.

CautionStrict bans on all fresh fruit have not been shown to reduce infection and may worsen caloric intake and quality of life. Focus on safe handling rather than unnecessary restriction.

## 핵심 개념

- **Neutropenic diet** — A food safety approach for patients with low neutrophil counts that emphasizes thorough cooking, washing produce, and avoiding unpasteurized items rather than banning all fresh foods.
- **Neutropenia** — An abnormally low absolute neutrophil count that increases susceptibility to infection, commonly occurring after induction chemotherapy.
- **Induction chemotherapy** — Initial intensive chemotherapy aimed at achieving remission in acute leukemia, often causing profound bone marrow suppression.
- **Foodborne pathogen** — A microorganism such as Salmonella, Listeria, or E. coli that can cause infection when contaminated food is ingested.

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