A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory data which reveals a platelet count of 25,000/mm3 (25 X109/L), which intervention should the nurse include in the plan of care?Reference Range

Platelets [150,000 to 400,000/mm" (150 to 400 x 109/L)]

Ensure a large gauge IV catheter is used to obtain blood samples.

Wrap bruised areas with elastic bandage dressings.

Remove cold and frozen foods from dietary trays.

Monitor urine and stool for occult blood regularly.

Answer and Explanation

The Correct Answer is D

A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient.

B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding.

C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts.

D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Avoiding tight-fitting clothes can help reduce intra-abdominal pressure, which may contribute to GERD symptoms, but it is not the most crucial instruction.

B. Minimizing intake of spicy foods can help decrease gastric irritation and reflux symptoms, but it is not the most important instruction.

C. Beginning a smoking cessation program is important for overall health and may help reduce GERD symptoms, but it is not the most critical instruction for managing GERD.

D. Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter. This instruction helps minimize reflux episodes and should be emphasized to the client with GERD.

A. The client's blood pressure readings will be less than 160/90 mm Hg. B. The nurse will encourage the client to walk thirty minutes every day. C. The client's family will repeat signs and symptoms about the disease. D. The client's daily blood pressure will be less than 140/80 mm Hg this month.

Correct Answer is D

Explanation

A. While controlling blood pressure is important in managing cardiovascular disease, the specific outcome should reflect the target blood pressure goal of less than 140/80 mm Hg to reduce the risk of complications.

B. Encouraging physical activity is beneficial for cardiovascular health, but the outcome should focus on blood pressure management, which is more directly related to the client's reported symptoms of blurred vision.

C. Educating the client's family about signs and symptoms of cardiovascular disease is important for support, but it does not directly address the client's blurred vision or cardiovascular risk factors.

D. Achieving a daily blood pressure reading of less than 140/80 mm Hg is an appropriate outcome to ensure adequate control of blood pressure and reduce the risk of cardiovascular complications, including those that may contribute to blurred vision.

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Naxlex Comprehensive Predictor Exams

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Correct Answer is D

Explanation

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is D

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

Patient Data. Exhibits Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize dropdown as the priority problem for this client, as evidenced by the client's statement, dropdown.

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only)