The practical nurse (PN) is caring for a client receiving chemotherapy who has thrombocytopenia. Which intervention is most important to include in the nursing plan of care?
Watch the client for abnormal bleeding.
Obtain the client's blood pressure frequently.
Maintain protective isolation precautions.
Observe for signs of dehydration.
The Correct Answer is A
A. Watch the client for abnormal bleeding: Thrombocytopenia increases the risk of spontaneous bleeding and hemorrhage. Monitoring for signs such as petechiae, ecchymosis, or bleeding from mucous membranes is the most critical safety measure.
B. Obtain the client's blood pressure frequently: While important for overall assessment, frequent BP monitoring does not directly prevent or detect bleeding unless invasive procedures are performed.
C. Maintain protective isolation precautions: Protective isolation primarily prevents infection, which is crucial for neutropenic clients but does not address the bleeding risk associated with low platelets.
D. Observe for signs of dehydration: Hydration is important in chemotherapy care but is secondary to preventing life-threatening bleeding in a client with thrombocytopenia.
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Related Questions
Correct Answer is D
Explanation
A. Increase the oxygen delivery by 10%: While hypoxemia is present, simply increasing oxygen may be insufficient for a client who is difficult to arouse and in severe respiratory distress. Immediate advanced airway intervention is a higher priority.
B. Administer PRN nebulizer treatment: Bronchodilators can improve airway obstruction but will not rapidly correct profound hypoxemia or altered mental status in a critically decompensating client. This intervention alone is not adequate.
C. Complete neurological assessment: Assessing neurological status is important, but the client’s low oxygen saturation and decreased responsiveness indicate a life-threatening situation that requires immediate intervention before completing a full assessment.
D. Prepare for rapid sequence intubation: The client exhibits severe hypoxemia, high respiratory rate, and decreased level of consciousness—signs of impending respiratory failure. Rapid sequence intubation ensures airway protection and adequate ventilation, which is the priority action to prevent respiratory arrest.
Correct Answer is C
Explanation
A. Complaints of nausea within 5 minutes after taking sips of water: Mild nausea postoperatively is common and can often be managed with antiemetics or slow oral intake. While it should be monitored, it does not require immediate escalation.
B. Oral temperature 100° F (37.7°C) 30 minutes after taking an analgesic: A low-grade fever is not unusual after surgery due to inflammation or early postoperative response. It warrants observation but is not an urgent finding.
C. Total urinary output of 20 mL for the past 2 consecutive hours: Oliguria after nephrectomy is a critical sign that may indicate impaired renal function or hypovolemia. Reporting this immediately allows timely intervention to prevent renal compromise and fluid-electrolyte imbalance.
D. Pain in left flank surgical site described as 6 on a 10 point scale: Moderate pain is expected postoperatively and can be managed with prescribed analgesics. It does not require immediate reporting unless accompanied by other acute complications.
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