A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?

Determine the client's blood type.

Institute bleeding precautions.

Avoid administering IV pain medication.

Implement airborne precautions.

Answer and Explanation

The Correct Answer is B

B. Petechiae indicate a risk of bleeding due to low platelet levels or dysfunction. Bleeding precautions aim to minimize the risk of injury and bleeding events.

A While knowing the blood type is generally important for medical management, it is not the immediate priority based on the presence of petechiae alone.

C. Intravenous pain medications, especially those that can affect platelet function (like NSAIDs), may increase the risk of bleeding.

D. Airborne precautions are used for diseases transmitted by airborne droplets smaller than 5 microns, such as tuberculosis or measles. Petechiae are not indicative of an airborne disease transmission risk.

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Correct Answer is D

Explanation

D. Wearing goggles or eye protection when irrigating a wound helps prevent splashes or sprays of contaminated fluid from entering the nurse's eyes.

A Gowns are typically used during direct patient contact if there is an expectation of substantial contact with blood or body fluids.

B Sterile gloves are not typically required for administering an intramuscular (IM) injection. Instead, clean non-sterile gloves are sufficient to maintain aseptic technique during the procedure.

C. Recapping needles using both hands can increase the risk of needlestick injuries. It is recommended to use a one-handed scoop method or a safety device to recap needles safely.

A. Generalized abdominal pain B. Increased heart rate C. Cloudy effluent D. Fever

Correct Answer is C

Explanation

C. Cloudy effluent is one of the earliest and most specific signs of peritonitis. It warrants immediate evaluation and diagnostic testing to confirm the diagnosis and initiate appropriate treatment.

A Generalized abdominal pain is a common symptom of peritonitis but may not be the earliest indication.

B. Tachycardia (increased heart rate) can occur in response to infection or inflammation, including peritonitis. It is a systemic response rather than a localized symptom.

D. Fever can also be associated with peritonitis but may appear later and is not as specific early indicators

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A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?

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Explanation

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Correct Answer is C

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