The RN is caring for a client admitted secondary to the side effects of chemotherapy. The client has been diagnosed with thrombocytopenia. Which of the following would be an appropriate intervention?

Measure abdominal girth twice weekly.

Apply pressure to needlestick sites for 10 minutes.

Monitor for the presence of WBCs in the urine.

Assess core temperatures using a rectal thermometer

Answer and Explanation

The Correct Answer is B

Rationale:
A. Measuring abdominal girth is more relevant for conditions like ascites or bowel obstruction, not thrombocytopenia.
B. Thrombocytopenia (low platelet count) increases bleeding risk, so applying pressure to needlestick sites for an extended time (at least 10 minutes) is an appropriate and essential intervention.
C. Monitoring for white blood cells in urine is associated with infection, which is more relevant for neutropenia.
D. Rectal thermometers should be avoided in clients with thrombocytopenia due to risk of rectal trauma and bleeding.

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Correct Answer is D

Explanation

Rationale:
A. Hypersensitivity reactions to cisplatin typically involve symptoms like rash, shortness of breath, or facial swelling—not fatigue alone.
B. Hypercalcemia is more commonly associated with cancers like multiple myeloma or bone metastases, and it usually causes confusion, nausea, or constipation—not just fatigue.
C. Hepatomegaly may occur in metastatic disease but is not a routine complication of cisplatin and is less directly linked to fatigue.
D. Fatigue in a client receiving chemotherapy such as cisplatin is commonly due to anemia, a result of bone marrow suppression. Checking the complete blood count (CBC) is essential to assess for decreased red blood cells or other cytopenias.

A. Encourage the client to ambulate and increase fluid intake to stimulate urination B. Check the client's bladder for distention and notify the healthcare provider if necessary. C. Increase the client's fluid intake and reassess the output in 4 hours. D. Administer the prescribed pain medication and document the findings

Correct Answer is B

Explanation

Rationale:
A. Encouraging ambulation and fluids may help, but the low urine output (oliguria) over 3 hours warrants assessment of bladder distention first to rule out urinary retention.
B. Checking the bladder for distention is the most appropriate immediate action, as urinary retention is a common postoperative complication that can cause pain and reduced output. The healthcare provider should be notified if retention is present.
C. Increasing fluids alone without assessment may delay necessary intervention.
D. Administering pain medication without assessing the cause of decreased output may mask symptoms and delay diagnosis of urinary retention or other complications.

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The RN is caring for a client admitted secondary to the side effects of chemotherapy. The client has been diagnosed with thrombocytopenia. Which of the following would be an appropriate intervention?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving cisplatin, a chemotherapy agent, to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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