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 B
Explanation
A. This is partially correct but lacks the detail that the examination is done via an endoscope through the throat.
B. An endoscopic retrograde cholangiopancreatography (ERCP) involves the use of an endoscope to visualize and treat problems in the bile ducts, gallbladder, and pancreas.
C. This statement reflects a misunderstanding of the procedure, as ERCP does not involve shock waves to treat gallstones.
D. This statement also reflects a misunderstanding, as ERCP is primarily a diagnostic procedure and does not involve direct medication delivery to the gallbladder.
Correct Answer is D
Explanation
A. Heat application may provide comfort for localized pain but does not address the underlying cause of hypercalcemia, which requires systemic management.
B. While rest may be beneficial for certain conditions, it does not directly address hypercalcemia. Encouraging mobility and adequate fluid intake is typically more effective.
C. Coughing and deep breathing exercises are important for preventing respiratory complications after surgery but are not relevant for managing hypercalcemia.
D. Increasing fluid intake promotes hydration and enhances urinary calcium excretion, helping to lower serum calcium levels and minimize complications associated with hypercalcemia
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