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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Jaundice is typically not visible in the webbed areas of the fingers.

B. The nail beds are part of the skin that can show jaundice, but they may also be aﬀected by other factors such as anemia, cyanosis, or nail polish.
C. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
D. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.

A. To reduce risk of infection B. To dry gastric secretions C. To promote postoperative healing D. To correct a clotting problem

Correct Answer is D

Explanation

A. While vitamin K plays a role in immune function, its administration prior to surgery primarily aims to correct potential clotting abnormalities rather than prevent infection.

B. Vitamin K does not affect gastric secretions. Its role in this context is unrelated to gastric function.
C. While vitamin K is involved in various physiological processes, its administration prior to surgery is primarily aimed at preventing bleeding complications by ensuring adequate clotting factor synthesis.
D. Vitamin K is essential for the synthesis of clotting factors in the liver.

Administering vitamin K prior to surgery helps ensure adequate levels of clotting factors, reducing the risk of bleeding during and after the procedure.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is African American has cholecystitis. Which of the following areas should the nurse inspect to monitor for the presence of jaundice?

Correct Answer is C

Explanation

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Correct Answer is D

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