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","C","E"]

Explanation

A. A back massage (A) can be soothing and may help with circulation, but it's not typically a priority immediately postoperative.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques empower the client to actively participate in their comfort and recovery process.

C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) due to shallow breathing. Coughing and deep breathing exercises help to expand lung volume, clear secretions, and prevent respiratory complications. It's important to encourage and assist the client in performing these exercises regularly.
D. Encouraging the client to turn every 4 hours helps prevent pressure ulcers and promotes good circulation, but turning might be more frequent depending on the surgery and the client's condition.
E. Pain management is crucial for postoperative comfort and recovery. Administering analgesics as needed helps to control pain effectively, which is essential for the client to participate in activities such as deep breathing, coughing, and moving, thereby reducing the risk of complications.

A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

Correct Answer is D

Explanation

A. Metabolic alkalosis is characterized by an increase in bicarbonate (HCO3-) levels in the blood, resulting in an elevated pH (>7.45). Shallow respirations are less likely to cause metabolic alkalosis directly.
B. This is not likely the initial risk. Respiratory alkalosis occurs due to hyperventilation, leading to excessive elimination of CO2 (carbon dioxide), which raises the blood pH (>7.45). Shallow respirations typically result in retention of CO2, leading to respiratory acidosis rather than alkalosis.
C. Metabolic acidosis occurs when there is an increase in acid (decreased pH <7.35) or a decrease in bicarbonate levels in the blood. Shallow respirations can lead to hypoventilation and retention of CO2, resulting in respiratory acidosis initially.
D. Shallow respirations at a rate of 9 breaths per minute reduce the elimination of CO2, leading to its accumulation in the blood. This accumulation lowers the blood pH (<7.35), causing respiratory acidosis. Therefore, the client is initially at risk for developing respiratory acidosis due to ineffective ventilation.

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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","C","E"]

Explanation

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Correct Answer is D

Explanation

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