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 ["B","E"]

Explanation

A. Auscultating the brachial pulse is not typically used to assess the patency of an arteriovenous fistula.
B. A thrill is a vibration felt over an arteriovenous fistula or graft and indicates proper blood flow. Palpation for thrill is a standard method to assess fistula patency.
C. Blood pressure measurement does not directly assess the patency of an arteriovenous fistula.
D. Auscultating the radial pulse is not typically used to assess the patency of an arteriovenous fistula.
E. A bruit is a swooshing sound heard over an arteriovenous fistula or graft and indicates turbulent blood flow. Auscultating for bruit is another method to assess fistula patency.
F. Palpate the right radial pulse: Palpating the radial pulse is not typically used to assess the patency of an arteriovenous fistula.

A. Rhythm: Irregularly irregular B. P waves: No identifiable P waves C. PR interval: Measurable D. Heart rate: Atrial rate not measurable E. QRS interval: <0.10 seconds

Correct Answer is ["A","B","D"]

Explanation

A. Irregularly irregular: Atrial fibrillation is characterized by an irregularly irregular rhythm.
B. No identifiable P waves: P waves are typically absent in atrial fibrillation or may be difficult to identify.
C. PR interval is not typically measured in atrial fibrillation as it is not relevant to the rhythm.
D. Atrial rate not measurable: The atrial rate in atrial fibrillation is not measurable due to the rapid and irregular nature of the rhythm.
E. QRS interval is typically normal in atrial fibrillation and does not exceed 0.10 seconds.

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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

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Correct Answer is ["B","E"]

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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