The nurse reviews the laboratory test results for a client diagnosed with leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 cells/mm3(reference range 150,000 - 450,000). The nurse should prepare to implement a specific action based on this finding.

Call the dietary department to report that the client needs to be on a low-bacteria diet

Remove the fresh flowers from the client's room

Instruct the family members to wear a mask when in the client's room

Remove the rectal thermometer from the client's room

Answer and Explanation

The Correct Answer is D

Rationale:
A. A low-bacteria diet is more relevant for clients with neutropenia, not thrombocytopenia.
B. Removing fresh flowers is also a precaution for infection prevention in immunocompromised (neutropenic) patients, not bleeding risk.
C. Family members wearing masks is an infection control measure for clients with low white blood cell counts, not low platelets.
D. A platelet count of 20,000 cells/mm³ indicates severe thrombocytopenia, putting the client at high risk for bleeding. Rectal thermometers can cause mucosal trauma and bleeding and should be avoided. Removing it is the appropriate safety measure in this scenario.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Notifying the healthcare provider is important but the nurse’s first priority is assessing the client’s overall status.
B. Reassurance without assessment ignores the potential seriousness of a hematoma.
C. Monitoring for signs of shock (hypotension, tachycardia) is the priority action because a hematoma can cause significant blood loss leading to hypovolemic shock.
D. Warm compresses are generally not recommended immediately after hematoma formation, as they may increase bleeding or swelling.

A. Activities that could result in bleeding B. Oral fluid intake between meals only C. Fresh flowers and potted plants in the room D. All visitors are banned from entering the client's room.

Correct Answer is C

Explanation

Rationale:
A. Activities that could result in bleeding are more appropriate precautions for clients with thrombocytopenia, not neutropenia.
B. Restricting oral fluids to between meals is unnecessary and may lead to inadequate hydration, especially during cancer treatment.
C. Fresh flowers and potted plants can harbor bacteria and fungi, which pose a significant infection risk to neutropenic clients. These should be restricted.
D. A complete ban on visitors is unnecessary. Visitors should be screened for illness and follow hand hygiene protocols, but supportive visitation is still encouraged when safe

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse reviews the laboratory test results for a client diagnosed with leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 cells/mm3(reference range 150,000 - 450,000). The nurse should prepare to implement a specific action based on this finding.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who underwent a mastectomy 24 hours ago is found to have a hematoma in the surgical site, as evidenced by increased swelling and a firm, bluish discoloration. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer and who has neutropenia. Which of the following restrictions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include?

A 20-year-old client presents to the emergency department with abdominal pain. Which assessment finding is most indicative of acute appendicitis?

A nurse is performing the health history and physical assessment of a client diagnosed with rheumatoid arthritis (RA). What assessment is most consistent with the clinical presentation of RA?

A nurse is caring for a client who has undergone a total hip replacement. The nurse reviews health education with the patient before discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching?

A nurse is caring for a client who is 24 hours post-hysterectomy. The client is experiencing moderate abdominal pain and is requesting pain medication. The nurse notices the client's urinary output is 45 mL over the past 3 hours. Which of the following is the most appropriate nursing action?

The nurse is assessing a client who is 2 days postoperative from a colostomy. Which of the following findings should the nurse report to the healthcare provider immediately?

A nurse is educating a client with gout about lifestyle modifications that can help control the signs and symptoms of the disease. What recommendation should the nurse make?

The nurse is providing discharge teaching for a client who developed a pulmonary embolism after total knee surgery. The client has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client?