An adult male client is admitted to the medical unit because of a loss of appetite and generalized malaise. His complete blood count (CBC) results indicate a white blood cell (WBC) count of 8,000/mm³ (8 x 10⁹/L), basophils 1% (0.01 fraction), platelets 98,000/mm³ (98 x 10⁹/L), hemoglobin of 14 g/dL (8.7 mmol/L), and hematocrit of 44.9% (0.44 volume fraction). The practical nurse (PN) should assess the client for which finding?
Reference Range:
- White Blood Cell (WBC): 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L)
- Basophils: 0.5 to 1.0% (0.01 to 0.05 x 10⁹/L)
- Platelets: 150,000 to 400,000/mm³ (150 to 400 x 10⁹/L)
- Hemoglobin (Hgb): 14 to 18 g/dL (8.69 to 11.17 mmol/L)
- Hematocrit (Hct): 42% to 52% (0.42 to 0.52 volume fraction)
Flushed, hot skin.
Hives.
Inelastic turgor.
Bruising.
The Correct Answer is D
Choice A reason: Flushed, hot skin is not directly related to the client's CBC results. This symptom can indicate various conditions, such as fever, inflammation, or an allergic reaction, but it does not specifically correlate with the lab findings provided. The client's WBC count, hemoglobin, hematocrit, and basophils are within normal ranges, and the most significant abnormality is the low platelet count.
Choice B reason: Hives, or urticaria, are typically associated with allergic reactions and not directly related to the client's CBC results. While a low platelet count can sometimes be associated with immune-mediated conditions, hives are not a primary symptom of thrombocytopenia (low platelet count). The main concern with a low platelet count is the increased risk of bleeding and bruising.
Choice C reason: Inelastic turgor is a sign of dehydration or poor skin elasticity, often seen in conditions such as severe dehydration or malnutrition. The client's CBC results do not indicate dehydration or issues with skin turgor. The hemoglobin and hematocrit levels are within normal ranges, suggesting that the client's overall fluid status is likely stable.
Choice D reason: Bruising is the most relevant finding to assess for in a client with a low platelet count (thrombocytopenia). Platelets play a crucial role in blood clotting, and a low platelet count increases the risk of bleeding and easy bruising. The client's platelet count of 98,000/mm³ (98 x 10⁹/L) is below the normal range, which predisposes them to bruising and potential bleeding complications. It is important for the practical nurse to assess for signs of bruising and bleeding and to monitor the client closely for any further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Administering a PRN prescription for an antiemetic is not the first action to take in this situation. Shaking and feelings of nausea and vomiting during a blood transfusion can indicate a possible transfusion reaction, which is a serious and potentially life-threatening event. While managing symptoms like nausea is important, the immediate priority is to stop the transfusion to prevent further complications.
Choice B reason: Flushing the IV tubing with sodium chloride is not the appropriate first step. Before addressing the IV line, it is crucial to stop the blood infusion to prevent any more blood from entering the client's system, which could exacerbate a potential transfusion reaction. After stopping the infusion, flushing the line can be considered to maintain IV access, but it is not the initial action to take.
Choice C reason: Notifying the healthcare provider is necessary, but it is not the first action to take. Immediate intervention is required to prevent further administration of the potentially problematic blood product. Once the infusion is stopped, the healthcare provider should be notified promptly so that appropriate assessments and interventions can be initiated.
Choice D reason: Turning off the blood infusion is the first and most critical action to take. This step immediately stops the administration of the blood product, preventing further exposure to the potential cause of the reaction. Once the infusion is stopped, the PN can then proceed to assess the client's vital signs, notify the healthcare provider, and follow the institution's protocol for managing transfusion reactions. Ensuring the client's safety by stopping the infusion is the top priority.
Correct Answer is A
Explanation
Choice A reason: Using a large cuff to obtain BP readings on either thigh is the appropriate action. With a history of a right radical mastectomy, blood pressure should not be taken on the right arm due to the risk of lymphedema. The left arm is also not suitable due to the recent surgery and cast. Therefore, the thigh is the best alternative site for accurate BP measurement.
Choice B reason: Measuring all vital signs every 2 hours except the BP is not appropriate because BP is a critical vital sign that needs to be monitored regularly, especially in postoperative clients. Omitting BP measurements could miss important changes in the client's condition.
Choice C reason: Obtaining manual BP readings with a cuff on the left arm is not recommended as the client has a recent surgical repair and cast on the left arm. This can cause discomfort and may not provide accurate readings.
Choice D reason: Quickly releasing air from the BP cuff on the right arm is not suitable due to the client's history of right radical mastectomy. This practice could exacerbate the risk of developing lymphedema in the affected arm.
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