A client diagnosed with acute myelogenous leukemia (AML) develops a platelet count of 10,000 mm3 during chemotherapy treatment. What is an appropriate nursing intervention for this client, based on this finding?

Table 34.1 Review of Normal Ranges for Complete Blood Cell Counts (Adult)

Blood Cell

Normal Ranges

Red blood cells (mature, circulating)

Male: 451-6.01 million/mm3

Female: 4.01-5.51 million/mm3

Hemoglobin

Adult (15-64 yr)

Male 14-17.3 g/dL

Female 11.7-155 g/dL

Hematocrit

42%-52% in males

36% -48% in females

Reticulocytes

0.5% -2.5% of total RBC count

White blood cells (total)

4.5-11.1 10/mm3

Neutrophils

59%

Bands 3% Segs-56%

Eosinophils

2.7%

Basophils

0.5%

Lymphocytes

34%

Monocytes

4%

Platelets

150,000-450,000/mm3

Obtain a prescription for stool occult blood testing

Encourage intake of oral fluids to 3000 mL/day

Assess the temperature every four hours

Provide oral hygiene every two hours

Answer and Explanation

The Correct Answer is C

A.   This intervention can be appropriate since a very low platelet count increases the risk of bleeding, including gastrointestinal bleeding. However, this action alone does not directly address the immediate risks associated with the low platelet count.
B.   While hydration is important for overall health, this intervention does not specifically address the risks associated with a low platelet count. Additionally, excessive fluid intake may not be appropriate for all patients, especially if there are underlying kidney issues or fluid restrictions.
C.   Clients with AML and low platelet counts are at increased risk for infections and may develop febrile neutropenia. Monitoring temperature every four hours can help detect early signs of infection, allowing for timely intervention.
D.   While maintaining oral hygiene is important, especially in patients undergoing chemotherapy, this intervention may not be the most critical action based on the acute concern of a very low platelet count. However, it is important to note that patients with low platelet counts may also experience bleeding from the gums, making gentle oral care essential.

Nursing Test Bank

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Correct Answer is A

Explanation

A. The elevated pH and decreased PaCO2 indicate that the respiratory system is causing alkalosis, typically due to hyperventilation (excessive breathing).
B. Metabolic alkalosis would be indicated by a high pH with a normal or high HCO3. Since the HCO3 level is normal and the PaCO2 is low, this does not fit the picture of metabolic alkalosis.
C. Respiratory acidosis would be characterized by a low pH and an elevated PaCO2 due to inadequate ventilation and accumulation of carbon dioxide. Here, the pH is high, and the PaCO2 is low.
D. Metabolic acidosis would be indicated by a low pH with a low HCO3. In this case, the pH is high, and the HCO3 is normal.

A. 1500 B. 1200 C. 1100 D. 0200

Correct Answer is C

Explanation

A. 1500 is 8 hours after 0700, which is too long for the remaining fluid to last.
B. 1200 is 5 hours after 0700, which means there would still be fluid left in the bag at this time.
C. 1100 is exactly 4 hours after 0700, which aligns with our calculation of when the remaining 500 mL will be finished.
D. 0200 is 19 hours after 0700, which is far too late for the IV fluid to last.

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ABG Value	Normal Range
PH	7.35-7.45
PaCO2	35-45 mm Hg
HCO3-	22-26 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male: 451-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-155 g/dL
Hematocrit	42%-52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 10/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse receives report at 0700 on a client who has 500 mL of IV fluid left in the bag. The IV is running at 125 mL per hour. At what time should the nurse expect to change the bag (military time)?

Correct Answer is C

Explanation

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