A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks:
Complete the following sentence by using the lists of options. The client is at risk for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
The client is at risk for Bleeding as evidenced by the Decrease in Platelet count from 350,000/mm² to 100,000/mm².
Rationale for Bleeding: Platelets are a crucial component of the blood that helps in clotting and preventing excessive bleeding. A decrease in platelet count from 350,000/mm² to 100,000/mm² is significant and puts the client at risk for bleeding. This is because when platelet levels fall below the normal range (150,000 to 400,000/mm²), the body’s ability to form clots and stop bleeding is compromised.
Rationale for Anemia: The client’s Hemoglobin level has decreased from 15 g/dL to 12 g/dL, which is at the lower end of the normal range (12 to 16 g/dL). However, it is still within the normal range, so the client is not currently at risk for anemia.
Rationale for Infections: The client’s White Blood Cell (WBC) count has decreased from 8,000/mm² to 6,000/mm², but it is still within the normal range (5,000 to 10,000/mm²). Therefore, the client is not currently at risk for infections.
Rationale for Cardiac arrhythmias: The client’s Potassium level has slightly decreased from 3.7 mEq/L to 3.6 mEq/L, but it is still within the normal range (3.5 to 5 mEq/L). Therefore, the client is not currently at risk for cardiac arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A lesion with uniform pigmentation is not typically a sign of skin malignancy. Most benign moles are uniform in color, including shades of tan, brown, and black.
Choice B rationale
The new appearance of petechiae, or small, pinpoint hemorrhages under the skin, is not typically associated with skin cancer. Petechiae can be a sign of a number of conditions, including certain infections, low platelet count, or certain medications.
Choice C rationale
A mole with an asymmetrical appearance is a potential indication of skin malignancy. Asymmetry, where one half of the mole does not match the other, is one of the ABCDEs (Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, and Evolving size, shape, or color) of melanoma detection.
Choice D rationale
The presence of a papule, a small, raised bump on the skin, is not necessarily indicative of skin cancer. Papules can be a sign of many different skin conditions, including acne, skin infections, or dermatitis.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
The nurse should stop the IV infusion. The client has manifestations of IV infiltration, which occurs when IV fluid enters the surrounding tissue. Stopping the IV infusion and removing the IV catheter can reduce the risk for further tissue damage.
Choice B rationale
The nurse should elevate the client’s left arm. Elevation can help decrease swelling and reduce the risk for tissue damage.
Choice C rationale
The nurse should apply heat to the client’s left hand. Heat can help reduce swelling and promote comfort.
Choice D rationale
Starting a new IV in the client’s left hand is not recommended at this point. The nurse should first manage the infiltration and then assess the need for a new IV3.
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