An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL during chemotherapy is to
check all stools for occult blood.
encourage fluids to 3000 mL/day.
provide oral hygiene every 2 hours.
check the temperature every 4 hours.
The Correct Answer is A
A. Correct. A platelet count <20,000/μL increases bleeding risk. Checking for occult blood helps detect hidden gastrointestinal bleeding.
B. Incorrect. Hydration is important but does not directly address thrombocytopenia management.
C. Incorrect. While oral hygiene is important, frequent brushing could cause bleeding with low platelets.
D. Incorrect. Monitoring temperature is important for infection risk but does not address bleeding concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Placing a pillow under the patient's head is inappropriate because it may obstruct the airway and does not prevent aspiration.
B. Loosening restrictive clothing can be helpful but is not the priority over airway protection.
C. Clearing the area of hazards is important to prevent injury, but airway protection takes precedence.
D. Positioning the patient in a side-lying position is the priority to maintain airway patency and reduce the risk of aspiration in case of vomiting.
Correct Answer is C
Explanation
A. Inserting an indwelling urinary catheter – Incorrect. While catheterization may be necessary, it is not the highest priority for an unconscious patient.
B. Putting a nasogastric (NG) tube in place – Incorrect. NG tube placement can be useful for feeding or decompressing the stomach, but airway management takes precedence.
C. Maintaining a patent airway – Correct Answer. Airway patency is the top priority in an unconscious patient to prevent aspiration, hypoxia, or respiratory failure.
D. Administering an enema daily – Incorrect. This is not a priority in unconscious patients.
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