A nurse is collecting data from a client who has leukemia. Which of the following findings has the highest priority?
Platelet count 125,000/mm3
Hematocrit 35%
Weight loss
Bone pain
The Correct Answer is A
A. A platelet count of 125,000/mm³ is lower than normal, and poses an increased risk of bleeding requiring immediate attention.
B. A hematocrit of 35% falls within the normal range for many individuals and does not indicate an urgent issue.
C. Weight loss may be a concern but is not typically considered a priority over other symptoms such as bone pain.
D. Bone pain in a client with leukemia is a common symptom of leukemia but does not require immediate attention compared to a low platelet count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Coffee is generally well tolerated unless the patient experiences discomfort or adverse effects from caffeine. It does not typically pose specific risks for patients with Hodgkin's disease.
B. Orange juice is generally safe to consume unless the patient has specific dietary restrictions or intolerances. It provides vitamin C and hydration.
C. Ginger ale is a non-caffeinated, carbonated beverage that is often used to alleviate nausea and upset stomach. It is generally safe to consume for patients with Hodgkin's disease unless there are individual sensitivities.
D. Alcohol consumption, including wine, should be avoided by patients with Hodgkin's disease, especially during treatment. Alcohol can suppress the immune system and may interact with medications or exacerbate side effects.
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