A nurse is assisting with the plan of care for a client who has leukemia and whose platelet count is 50,000 mm. Which of the following interventions should the nurse include in the plan of care?
Use contact precautions.
Administer ibuprofen prior to assisting with ADLS
Measure rectal temperature every 4 hr.
Administer a stool softener.
The Correct Answer is D
A. Leukemia itself doesn't necessitate contact precautions unless there are other specific infectious concerns, which are not mentioned in this scenario.
B. Ibuprofen is contraindicated in patients with low platelet counts due to the risk of bleeding. Therefore, administering ibuprofen would exacerbate the risk of bleeding in this patient.
C. Invasive procedures like rectal temperature measurements should be avoided in patients with low platelet counts due to the risk of bleeding. Thus, this intervention increases the risk of harm to the patient.
D. Patients with low platelet counts are at risk for bleeding, including gastrointestinal bleeding. Administering a stool softener can help prevent straining during bowel movements, reducing the risk of bleeding and promoting patient comfort and safety.
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Related Questions
Correct Answer is D
Explanation
A. While patients receiving chemotherapy are at risk for infections due to immunosuppression, the risk of overwhelming infection, particularly from encapsulated bacteria, is higher in post-splenectomy patients due to impaired immune function without the spleen.
B. Patients with sickle cell anemia are at increased risk of infections, particularly from encapsulated bacteria, due to functional asplenia or hyposplenism, but the risk of overwhelming infection is highest in post-splenectomy patients.
C. Patients with multiple myeloma are immunocompromised and at increased risk of infections, but they do not have the same risk of overwhelming infection as post- splenectomy patients.
D. Post-splenectomy patients are at highest risk of overwhelming infection due to impaired immune function resulting from the absence of the spleen, which plays a crucial role in immune surveillance and defense against encapsulated bacteria.
Correct Answer is B
Explanation
A. While bone involvement can occur in Hodgkin lymphoma, it is not typically associated with a high risk of spontaneous pathological fractures compared to multiple myeloma.
B. Multiple myeloma is characterized by the destruction of bone tissue, leading to an increased risk of spontaneous pathological fractures.
C. Leukemia primarily affects the bone marrow and may cause bone pain but does not typically lead to spontaneous pathological fractures.
D. Hemophilia is a bleeding disorder characterized by a deficiency in clotting factors and is not directly associated with an increased risk of spontaneous pathological fractures.
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