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A nurse is reviewing the medical record for a client who has acute leukemia

Exhibits

Select words from the choices to fill in each blank in the following sentence The client is at risk for developing

and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Bleeding: The client's platelet count has dropped from 160,000/mm³ to 100,000/mm³, which is below the normal range (150,000 to 400,000/mm³). Platelets are essential for blood clotting, and a low count increases the risk of bleeding. Additionally, the prolonged PT (13.5 seconds) and elevated INR (2.2) further indicate a tendency toward bleeding.

Infection: The client's WBC count remains elevated at 15,500/mm³, which can be indicative of ongoing infection or inflammation. Patients with acute leukemia often have dysfunctional white blood cells, which impairs their ability to fight infections effectively.


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Related Questions

Correct Answer is ["A","B","D"]

Explanation

A. Irregularly irregular: Atrial fibrillation is characterized by an irregularly irregular rhythm.
B. No identifiable P waves: P waves are typically absent in atrial fibrillation or may be difficult to identify.
C. PR interval is not typically measured in atrial fibrillation as it is not relevant to the rhythm.
D. Atrial rate not measurable: The atrial rate in atrial fibrillation is not measurable due to the rapid and irregular nature of the rhythm.
E. QRS interval is typically normal in atrial fibrillation and does not exceed 0.10 seconds.

Correct Answer is C

Explanation

A. Daily weight monitoring is important for assessing fluid status but may not provide real-time information about fluid balance changes.
B. Vital signs are important for overall assessment but may not specifically address the nursing diagnosis of Excess Fluid Volume unless there are significant changes indicative of fluid overload or dehydration.
C. Monitoring intake and output provides direct information about fluid balance and renal function, helping to identify trends and assess the effectiveness of interventions aimed at managing fluid volume.
D. Skin turgor assessment is useful for evaluating hydration status but may not provide comprehensive data on fluid volume excess alone.

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