The nurse is caring for a client who has been taking aspirin 81mg PO daily for the last six months. Which clinical findings are of most concern? (SELECT ALL THAT APPLY)

Temperature elevation of 100.4 ORGAN

Hemoglobin decrease from 128g/dl to 9.5g/dl

Serum potassium increase from 3.5 mEq/L 4.5 mEq/L

Gastrointestinal discomfort prior to eating breakfast

Several areas of ecchymosis on upper and lower extremities

Answer and Explanation

Correct Answer : B,E

A. Temperature elevation of 100.4°F: While a slight fever can indicate infection or inflammation, it is not an immediate concern related to aspirin use. It requires monitoring but is not as critical as other findings.

B. Hemoglobin decrease from 128 g/dL to 5.5 g/dL: This significant drop in hemoglobin indicates severe anemia, which is a major concern and may suggest gastrointestinal bleeding, a known risk of long-term aspirin use.

C. Serum potassium increase from 3.5 mEq/L to 4.5 mEq/L: This level is still within the normal range and does not indicate a significant clinical issue. Normal potassium levels do not raise immediate concern.

D. Gastrointestinal discomfort prior to eating breakfast: While gastrointestinal discomfort can be a side effect of aspirin, it is not immediately alarming unless associated with more severe symptoms like bleeding or ulceration.

E. Several areas of ecchymosis on upper and lower extremities: This finding is concerning as it may indicate bleeding issues due to thrombocytopenia or increased bleeding tendency associated with aspirin therapy.

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Correct Answer is A

Explanation

A. Avoid needle sticks or other invasive procedures as much as possible: This is the most appropriate action for a client with thrombocytopenia. Since thrombocytopenia involves a low platelet count, the risk of bleeding is increased, and minimizing invasive procedures helps prevent complications.

B. Hold all stool softeners and laxatives until otherwise: This statement is not appropriate. Clients with thrombocytopenia should avoid straining during bowel movements, which can be facilitated by the use of stool softeners or laxatives if necessary.

C. Encourage vigorous tooth brushing with a soft bristle toothbrush: This is not advisable. While using a soft-bristled toothbrush is recommended, vigorous brushing could cause gum bleeding. Gentle oral hygiene practices should be emphasized instead.

D. Obtain a core temperature every 8 hours: While monitoring temperature is important, it is not specific to thrombocytopenia management. Other vital signs may be monitored more frequently, but this action does not directly address the primary concern of bleeding risk.

A. 2 inches 21 gauge B. 1 1/2 inch 27 gauge C. 5/8 inch 25 gauge D. 1/4 inch 19 gauge

Correct Answer is C

Explanation

A. 2 inches 21 gauge: This option is too long and too large in gauge for subcutaneous administration. Typically, a longer needle is not necessary for subcutaneous injections, especially for standard adult adipose tissue.

B. 1 1/2 inch 27 gauge: While this gauge is acceptable, the length is still longer than typically required for subcutaneous injections. A 1 1/2 inch needle is more suited for intramuscular injections.

C. 5/8 inch 25 gauge: This is the most appropriate choice for a subcutaneous injection. A 5/8 inch needle is typically adequate for subcutaneous tissue in adults, and a 25 gauge needle provides a suitable size for comfort while allowing the medication to be administered effectively.

D. 1/4 inch 19 gauge: This option is not suitable for subcutaneous injections. A 1/4 inch length is too short for effective penetration into subcutaneous tissue, and a 19 gauge needle is larger than necessary, which could increase discomfort.

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The nurse is caring for a client who has been taking aspirin 81mg PO daily for the last six months. Which clinical findings are of most concern? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

Which of the following actions should a nurse plan for when providing care for a client diagnosed with thrombocytopenia?

Correct Answer is A

Explanation

The nurse calculates that 0.74 mi of filgrastim must be administered to a client subcutaneously. The client weights 165 lbs. What length and gauge of needle is best to administer this medication?

Correct Answer is C

Explanation

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