A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Assess body temperature.

Monitor skin elasticity.

Observe the aspiration site.

Measure urinary output.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing body temperature is a routine post-procedure check but not the most critical for thrombocytopenia.

Choice B reason: Monitoring skin elasticity is not directly related to the risks associated with thrombocytopenia following a bone marrow biopsy.

Choice C reason: Observing the aspiration site is crucial because thrombocytopenia increases the risk of bleeding, and the site must be monitored for any signs of hemorrhage.

Choice D reason: Measuring urinary output is important but does not take precedence over monitoring the biopsy site for bleeding in a thrombocytopenic patient.

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

Explanation

Choice A Reason: A BMI of 28 kg/m² is considered overweight and is a modifiable risk factor for type 2 diabetes mellitus. Weight loss through diet and exercise can reduce the risk.

Choice B Reason: An HDL level of 43 mg/dL (1.11 mmol/L) is slightly below the recommended range and is a modifiable risk factor. Increasing HDL can be achieved through lifestyle changes such as exercise and dietary adjustments.

Choice C Reason: Having a sister with type 2 diabetes mellitus is a non-modifiable risk factor as it is related to genetic predisposition.

Choice D Reason: Occupational fume exposure is generally considered unrelated to the development of type 2 diabetes mellitus.

Choice E Reason: Cannabis use is typically unrelated to type 2 diabetes mellitus, though research on its long-term metabolic effects is ongoing.

Normal Ranges:

BMI: 18.5 to 24.9 kg/m² (normal)
HDL (High-Density Lipoprotein): Greater than 45 mg/dL (Greater than 1.15 mmol/L)
LDL (Low-Density Lipoprotein): Less than 130 mg/dL (Less than 3.4 mmol/L)
Fasting Blood Glucose: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)

A. Measure vital signs and telemetry pattern. B. Palpate and compare pedal pulse volumes. C. Measure post-procedure intake and output. D. Remove the dressing and observe the site.

Correct Answer is A

Explanation

Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.

Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.

Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.

Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.

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A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Review of History, Physical, and Laboratory Results Based on the findings, indicate whether each represents a modifiable risk factor, a non-modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

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

Explanation

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

Correct Answer is A

Explanation

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