A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?

Place the client on protective isolation.

Initiate measures to prevent venous thromboembolism.

Initiate droplet precautions.

Check the client's most recent platelet level.

Answer and Explanation

The Correct Answer is D

A. Protective isolation is not directly related to the symptoms of ecchymoses and petechiae but is more relevant for preventing infections in immunocompromised clients.
B. Measures to prevent venous thromboembolism are not the immediate concern given the bleeding symptoms; instead, managing platelet levels and bleeding risks is more critical.
C. Droplet precautions are not indicated based on the described symptoms, which are more related to bleeding disorders rather than infectious conditions requiring droplet precautions.
D. Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.

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Correct Answer is C

Explanation

A. A higher fluid intake, ideally 2 to 3 liters per day, is typically recommended to help flush uric acid from the body and prevent gout attacks, not just 1 to 1.5 L.
B. Aspirin is not recommended for gout pain management; nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids are more appropriate.
C. Focusing on losing weight to achieve a normal BMI is important for managing gout, as obesity is a risk factor for gout and can exacerbate symptoms. Weight loss can help reduce uric acid levels and improve overall management of the condition.
D. Allopurinol is used for long-term management to reduce uric acid levels and prevent attacks, but it is not used during acute attacks. Colchicine or NSAIDs are more appropriate for acute gout attacks.

A. Check the intravenous (IV) site for bleeding every 8 hours. B. Administer stool softeners. C. Check the client for proteinuria. D. Obtain body temperature readings every 4 hours.

Correct Answer is B

Explanation

A. Checking the IV site for bleeding is important but should be done more frequently in a client with thrombocytopenia (low platelet count), as bleeding can occur unexpectedly.
B. Administering stool softeners is a key intervention for clients with thrombocytopenia, as it helps to prevent straining during bowel movements, which could cause rectal bleeding due to fragile blood vessels.
C. Checking for proteinuria is not directly related to thrombocytopenia or the risk of bleeding. It is more commonly associated with kidney function monitoring.
D. Obtaining body temperature readings is important for infection monitoring, but it does not directly address the risk associated with a low platelet count, which primarily concerns bleeding.

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A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

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