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?
Implement airborne precautions.
Determine the client's blood type.
Institute bleeding precautions.
Avoid administering IV pain medication.
The Correct Answer is C
The nurse should institute bleeding precautions for the client.
Petechiae are small red or purple spots on the skin caused by broken capillaries, which can be a sign of low platelet count (thrombocytopenia) and an increased risk of bleeding.
Bleeding precautions include measures such as using a soft-bristled toothbrush, avoiding injections, and avoiding activities that could result in injury.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because determining the client’s blood type is not necessary in this situation.
Choice D is incorrect because avoiding IV pain medication is not necessary in this situation; however, the nurse should monitor the client for signs of bleeding and bruising.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should provide the client with a short-handled teacher.
This can help the client to reach and grasp objects without having to overextend or strain their unaffected arm.
Choice B is also correct.
The nurse should place a plate guard on the client’s meal tray.
This can help prevent food from spilling off the plate and make it easier for the client to eat with one hand.
Choice C is wrong because reminding the client to use a cane on his left side while ambulating could be unsafe as the client’s left side is affected by hemiplegia.
Choice D is wrong because positioning the bedside table on the client’s left side could make it difficult for the client to reach items on the table.
Correct Answer is B
Explanation
The nurse should consult the client before approaching the dog.
Service dogs are working animals and it is important to respect their role and the handler’s wishes.
Choice A is wrong because petting the dog briefly to demonstrate acceptance could distract the dog from its duties.
Choice C is wrong because offering the dog a bowl of water without consulting the client first could interfere with the dog’s training or schedule.
Choice D is wrong because commanding the dog to sit while talking with the client could confuse the dog and disrupt its training.
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