A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?

Check the IV site for bleeding every 8 hr

Obtain a rectal temperature every 8 hr.

Check the client for proteinuria.

Limit, IM injections.

Answer and Explanation

The Correct Answer is D

A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.

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Correct Answer is D

Explanation

A. A patient with a blue tag indicates minor injuries or illness and can wait for treatment.
B. A patient with a black tag is typically deceased or expected to die and is not a priority for immediate assessment.
C. A patient with a yellow tag indicates delayed treatment needs and can wait while more urgent cases are addressed.
D. A patient with a red tag indicates critical and life-threatening injuries requiring immediate assessment and intervention.

A. Humidify the client's room. B. Clean dentures in a denture cup. C. Serve cooked fruit with meals. D. Replace the water in flower vases with fresh water daily

Correct Answer is C

Explanation

A. Humidifying the client's room helps to maintain adequate moisture levels in the air. However, it is not specifically related to low WBC counts.
B. Cleaning dentures in a denture cup and serving cooked fruit with meals are good practices for hygiene and dietary considerations but do not directly address infection control.
C. Serving cooked fruit with meals can help minimize the risk of foodborne illnesses.
D. Replacing the water in flower vases with fresh water daily is important for preventing bacterial growth but is not as directly beneficial for infection prevention in this context.

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A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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