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

Explanation

A. While assessment and data collection are important, the priority in the presence of a life-threatening arrhythmia is to initiate immediate interventions to address the situation.
B. The nurse should immediately inform the healthcare provider about the life- threatening arrhythmia to obtain further guidance and potential orders for intervention.
C. Vital signs are important, but they should not delay immediate action when a life- threatening arrhythmia is present.

D. Administering antiarrhythmic medication may be necessary, but the nurse should first notify the healthcare provider to obtain orders and guidance before administering any medications.

A. cranberry juice B. chocolate bar C. jello (a gelatin dessert) D. an orange E. grapefruit juice

Correct Answer is ["A","C"]

Explanation

A. Cranberry juice is typically low in potassium and would be suitable for a patient instructed to limit potassium intake.
B. Chocolate is generally high in potassium and would not be a suitable snack for a patient limiting potassium intake.
C. Jello is typically low in potassium and can be a suitable snack for a patient limiting potassium intake.
D. Oranges are high in potassium and would not be suitable for a patient instructed to limit potassium intake.
E. Grapefruit juice is high in potassium and would not be suitable for a patient limiting potassium intake.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is ["A","C"]

Explanation

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