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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A platelet count of 125,000/mm³ is lower than normal, and poses an increased risk of bleeding requiring immediate attention.
B. A hematocrit of 35% falls within the normal range for many individuals and does not indicate an urgent issue.
C. Weight loss may be a concern but is not typically considered a priority over other symptoms such as bone pain.
D. Bone pain in a client with leukemia is a common symptom of leukemia but does not require immediate attention compared to a low platelet count.
Correct Answer is B
Explanation
A. While controlling carbohydrate intake may be beneficial for managing blood glucose levels in some cases, it is not a primary dietary concern for chronic kidney disease.
B. Patients with chronic kidney disease often need to limit potassium intake because the kidneys may have difficulty excreting excess potassium, leading to hyperkalemia.
C. While protein restriction may be necessary in advanced stages of chronic kidney disease to reduce the workload on the kidneys, complete elimination of protein is not recommended.
D. Sodium restriction is often recommended for patients with chronic kidney disease to help control blood pressure and fluid balance.
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