A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions?

Spontaneous bleeding

Infection

Oliguria

Hyperactive deep tendon reflexes

Answer and Explanation

The Correct Answer is A

A.   Thrombocytopenia (low platelet count) predisposes the client to spontaneous bleeding. This can manifest as petechiae (small red or purple spots on the skin), purpura (larger areas of purple discoloration), mucosal bleeding (such as nosebleeds or bleeding gums), or internal bleeding (such as gastrointestinal or intracranial bleeding). Monitoring for signs of bleeding is essential to promptly intervene and prevent complications.
B.   While infections can occur in any client, a low platelet count does not directly predispose the client to infection. Thrombocytopenia primarily affects hemostasis rather than immune function.
C.   Oliguria refers to decreased urine output, typically less than 400 mL/day in adults. It is not directly related to thrombocytopenia but may occur in conditions affecting kidney function or fluid balance.
D.   Hyperactive deep tendon reflexes can indicate neurological conditions or electrolyte imbalances but are not associated with thrombocytopenia.

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Correct Answer is B

Explanation

A. Metabolic alkalosis is characterized by a high pH (>7.45) and an elevated bicarbonate (HCO3-). The ABG results show a pH of 7.32 (which is acidic), PaCO2 of 48 mm Hg (slightly elevated), and HCO3- of 23 mEq/L (within normal range). These findings do not indicate metabolic alkalosis.
B. Respiratory acidosis is characterized by a low pH (<7.35) and an elevated PaCO2 (>45 mm Hg). The ABG results show a pH of 7.32 (acidic) and a PaCO2 of 48 mm Hg (slightly elevated). These findings are consistent with respiratory acidosis, where the elevated PaCO2 indicates inadequate ventilation leading to retention of carbon dioxide and subsequent acidosis.

C. Metabolic acidosis is characterized by a low pH (<7.35) and a decreased bicarbonate (HCO3-). The ABG results show a pH of 7.32 (acidic) and HCO3- of 23 mEq/L (normal). These findings are not indicative of metabolic acidosis.
D. Respiratory alkalosis is characterized by a high pH (>7.45) and a decreased PaCO2 (<35 mm Hg). The ABG results show a pH of 7.32 (acidic) and a PaCO2 of 48 mm Hg (elevated). These findings do not indicate respiratory alkalosis.

A. Apply a warm compress to the IV site. B. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency. C. Remove the IV saline lock. D. Inject the solution more slowly while flushing the IV saline lock

Correct Answer is D

Explanation

A. Applying a warm compress can help dilate the blood vessels, potentially improving circulation around the IV site. This can sometimes alleviate discomfort caused by irritation or infiltration. However, if there is significant pain or swelling, warm compresses may not be sufficient.
B. Applying firm pressure on the syringe plunger during the flush is not recommended. Excessive force could potentially cause damage to the vein or exacerbate pain and discomfort. It's important to flush gently to maintain patency and avoid causing further irritation or complications.
C. If the client reports pain above the IV saline lock and there are signs of infiltration (such as swelling, coolness, or blanching of the skin around the site), removing the IV saline lock may be necessary. Infiltration occurs when IV fluid leaks into the surrounding tissue instead of flowing into the vein, which can lead to discomfort and complications.
D. Injecting the solution more slowly during the flush can help minimize discomfort and reduce the risk of causing further damage. Slower infusion allows for better tolerance by the vein and surrounding tissues, decreasing the likelihood of pain or infiltration.

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A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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