A nurse is monitoring a client who is receiving chemotherapy and has a platelet count of 20,000 mm3. Which of the following findings should the nurse identify as the priority?
Fatigue
Anorexia
Bleeding
Fever
The Correct Answer is C
Choice A Reason: Fatigue is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as anemia, infection, or depression.
Choice B Reason: Anorexia is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as nausea, pain, or anxiety.
Choice C Reason: Bleeding is the priority finding for a client who has a low platelet count, as it indicates that the client is at risk of hemorrhage and shock due to impaired blood clotting.
Choice D Reason: Fever is not the priority finding for a client who has a low platelet count, but it may indicate an infection that requires prompt treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: N0 does not indicate presence of regional lymph node involvement, but absence of it. N1 to N3 indicate increasing degrees of regional lymph node involvement.
Choice B Reason: TIS does not indicate that a tumor has been resolved, but that it is in situ, meaning that it is confined to the original site and has not invaded deeper tissues.
Choice C Reason: T4 does not indicate a tumor at its smallest size, but at its largest size. T1 to T4 indicate increasing sizes or extents of the primary tumor.
Choice D Reason: M1 indicates tumor metastasis to a single site, meaning that the cancer has spread to another organ or distant lymph node. M0 indicates no distant metastasis.
Correct Answer is C
Explanation
The correct answer is: C. Provide the client with an antiemetic 2 hours prior to the chemotherapy.
Choice A reason:
Instructing the client to restrict food intake prior to treatment is not the best approach. While it might reduce nausea temporarily, it can lead to weakness and nutritional deficiencies. Chemotherapy patients need adequate nutrition to maintain their strength and immune function.
Choice B reason:
Encouraging the client to drink a carbonated beverage 1 hour before meals can sometimes help with mild nausea, but it is not as effective as antiemetic medications. Carbonated beverages may provide temporary relief but do not address the underlying cause of chemotherapy-induced nausea.
Choice C reason:
Providing the client with an antiemetic 2 hours prior to chemotherapy is the most effective action. Antiemetics are specifically designed to prevent nausea and vomiting associated with chemotherapy. Administering them before treatment helps to manage symptoms proactively, improving the client's comfort and ability to tolerate chemotherapy.
Choice D reason:
Advising the client to lie down after meals is not recommended as it can worsen nausea and increase the risk of gastroesophageal reflux. It is generally better for clients to remain upright for a period after eating to aid digestion and reduce nausea.
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