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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Protecting the skin of the radiation portal site from sunlight exposure is crucial to prevent further damage to the irradiated area, as the skin becomes more sensitive during radiation therapy.

B. Washing the skin inside the radiation portal site should be done gently with mild soap and water, as directed by the healthcare provider, to maintain cleanliness and prevent infection. However, excessive rubbing or scrubbing should be avoided to minimize irritation.

C. The ink marks of the portal are used as reference points for accurate delivery of radiation and should not be removed until instructed by the healthcare provider or radiation therapist.

D. Moisturizing the radiation portal site can help alleviate dryness and discomfort associated with radiation therapy, but it should be done sparingly and with products recommended by the healthcare provider to avoid potential interactions or interference with the treatment.

A. Heart Rate 105 beats/minute B. Client can now speak in full sentences without pausing. C. Lung sounds clear D. Respirations 16 breaths/minute E. Client reports, “It’s a lot easier to breathe now.” F. Blood Pressure 122/84 mmHg

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Correct Answers:

Indicates the Interventions Were Successful: A, B, C, D, E, F

No Indication that the Interventions Were Successful: None

Rationale:

The assessment data provided indicates a positive response to the interventions for the asthma attack. The decrease in heart rate from 112 to 105 beats per minute, alongside the client's ability to speak in full sentences without pausing, suggests an improvement in respiratory function. Clear lung sounds and a reduction in respiratory rate to 16 breaths per minute further support this conclusion. The client's subjective report of eased breathing and the maintenance of blood pressure within normal limits post-intervention are also indicative of successful treatment. These observations collectively demonstrate the effectiveness of the administered medications and oxygen therapy in managing the acute asthma symptoms presented by the client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

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?

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

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.

Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?

The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?