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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sipping fluids with each meal may help prevent dehydration and promote hydration but is not the most important dietary instruction post-gastric bypass surgery.
B. Chewing slowly and thoroughly is important for digestion but is not specific to post-gastric bypass dietary needs.
C. Reducing intake of fatty foods is important for overall health but is not the most critical dietary instruction post-gastric bypass surgery.
D. Eating small frequent meals is crucial after gastric bypass surgery to prevent complications such as dumping syndrome, promote adequate nutrient absorption, and manage portion sizes effectively.
Correct Answer is A
Explanation
A. Wearing braces on both wrists during the night can help maintain a neutral wrist position and alleviate pressure on the median nerve, reducing symptoms of carpal tunnel syndrome.
B. Notifying the healthcare provider may be necessary if symptoms worsen or if additional interventions are needed, but this is not the first-line intervention for managing symptoms at night.
C. Elevating the hands on two pillows at night may provide some relief, but it is not as effective as wearing wrist braces to maintain proper alignment and reduce pressure on the median nerve.
D. Applying cold compresses before bedtime may help reduce inflammation but is not specifically targeted at alleviating nighttime symptoms of carpal tunnel syndrome.
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