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

Explanation

Choice A reason: Symptoms of heartburn and pain relieved by eating can indeed be consistent with an ulcer, and a complete physical exam can help diagnose the condition and rule out other causes.

Choice B reason: While immediate medical evaluation is important, it is not specified that the symptoms are severe or life-threatening, so it may not be the best initial advice.

Choice C reason: Diet changes can help manage symptoms of heartburn and indigestion, but they may not be sufficient if an ulcer is present.

Choice D reason: It is incorrect to assure the client that the symptoms are only reflux, as ulcer pain can indeed be relieved by food, contrary to the statement.

A. "Is there any particular reason why you think this is your fault?" B. "You didn't do anything wrong." C. "With surgery, your baby should have a full recovery." D. "This must be a very difficult time for you." E. "This must be a very difficult time for you."

Correct Answer is D

Explanation

Choice A reason: Asking if there is a particular reason why the parent thinks it's their fault may inadvertently validate feelings of self-blame, which is not helpful in this sensitive situation.

Choice B reason: While reassuring the parent they did nothing wrong is true, it may not address the emotional support the parent needs at this moment.

Choice C reason: Promising a full recovery with surgery may be misleading and give false hope, as outcomes can vary and myelomeningocele often results in some degree of impairment.

Choice D reason: Acknowledging the parent's feelings and the difficulty of the situation provides emotional support and validation without assigning blame or making promises about the outcome.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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