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A nurse is admitting a 56-year old male patient who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

Neutropenic

Contact

Droplet

Bleeding

Answer and Explanation

The Correct Answer is D

A. Neutropenic – Used for low WBC count, not platelets.

B. Contact – Used for infections like C. diff or MRSA.

C. Droplet – Used for respiratory illnesses like flu or meningitis.

D. Bleeding – Correct Answer. A low platelet count increases the risk of bleeding, so bleeding precautions are necessary (e.g., soft toothbrush, avoiding IM injections, fall precautions).

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Correct Answer is C

Explanation

A. 8 hr – Incorrect. RBC transfusions must not exceed 4 hours due to the risk of bacterial growth and hemolysis.

B. 6 hr – Incorrect. Blood products should be infused within a maximum of 4 hours to prevent complications.

C. 4 hr – Correct Answer. The maximum infusion time for packed RBCs is 4 hours to reduce the risk of bacterial contamination and infection.

D. 2 hr – Incorrect. While blood is often infused within 2 hours, the maximum safe limit is 4 hours.

A. Infuse the transfusion at a rate of 200 mL/hr. B. Check the patient's vital signs every hour during the transfusion. C. Leave the patient 5 minutes after beginning the transfusion. D. Flush the blood tubing with dextrose 5% in water.

Correct Answer is B

Explanation

A. Infuse the transfusion at a rate of 200 mL/hr. – Incorrect. The initial infusion should be slow (e.g., 75-100 mL/hr) to monitor for reactions.

B. Check the patient's vital signs every hour during the transfusion. – Correct Answer. Frequent monitoring is necessary to detect adverse reactions, such as fever or hypotension.

C. Leave the patient 5 minutes after beginning the transfusion. – Incorrect. The nurse should remain with the patient for the first 15 minutes, as most transfusion reactions occur early.

D. Flush the blood tubing with dextrose 5% in water. – Incorrect. Only normal saline should be used to flush blood tubing, as dextrose can cause hemolysis.

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A nurse is admitting a 56-year old male patient who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

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