A client diagnosed with acute myelogenous leukemia (AML) develops a platelet count of 10,000 mm3 during chemotherapy treatment. What is an appropriate nursing intervention for this client, based on this finding?
Table 34.1 Review of Normal Ranges for Complete Blood Cell Counts (Adult)
|
Blood Cell |
Normal Ranges |
|
Red blood cells (mature, circulating) |
Male: 451-6.01 million/mm3 Female: 4.01-5.51 million/mm3 |
|
Hemoglobin |
Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-155 g/dL |
|
Hematocrit |
42%-52% in males 36% -48% in females |
|
Reticulocytes |
0.5% -2.5% of total RBC count |
|
White blood cells (total) |
4.5-11.1 10/mm3 |
|
Neutrophils |
59% Bands 3% Segs-56% |
|
Eosinophils |
2.7% |
|
Basophils |
0.5% |
|
Lymphocytes |
34% |
|
Monocytes |
4% |
|
Platelets |
150,000-450,000/mm3 |
Obtain a prescription for stool occult blood testing
Encourage intake of oral fluids to 3000 mL/day
Assess the temperature every four hours
Provide oral hygiene every two hours
The Correct Answer is C
A. This intervention can be appropriate since a very low platelet count increases the risk of bleeding, including gastrointestinal bleeding. However, this action alone does not directly address the immediate risks associated with the low platelet count.
B. While hydration is important for overall health, this intervention does not specifically address the risks associated with a low platelet count. Additionally, excessive fluid intake may not be appropriate for all patients, especially if there are underlying kidney issues or fluid restrictions.
C. Clients with AML and low platelet counts are at increased risk for infections and may develop febrile neutropenia. Monitoring temperature every four hours can help detect early signs of infection, allowing for timely intervention.
D. While maintaining oral hygiene is important, especially in patients undergoing chemotherapy, this intervention may not be the most critical action based on the acute concern of a very low platelet count. However, it is important to note that patients with low platelet counts may also experience bleeding from the gums, making gentle oral care essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This option is primarily aimed at promoting lung expansion and preventing atelectasis (collapse of the lung). While it's an important post-operative intervention, it does not directly reduce the risk of embolic events related to venous thromboembolism.
B. Reporting significant pain (8/10) may indicate complications such as infection or improper healing, but it does not directly relate to reducing the risk of embolic events. While managing pain is important for recovery, simply reporting it does not contribute to preventing VTEs.
C. Assessing popliteal pulses is part of a thorough circulatory assessment, but it mainly focuses on blood flow to the lower extremities rather than preventing embolic events. It can help identify existing DVT but does not actively reduce the risk of embolism.
D. This statement is true and is the best choice for decreasing the risk of an embolic event. Early ambulation promotes venous return, improves circulation, and significantly lowers the risk of DVT and pulmonary embolism in post-operative patients. Encouraging patients to get out of bed and move around as soon as they are stable is a key nursing intervention in post-operative care.
Correct Answer is B
Explanation
A. This statement is false in terms of being a major risk factor for cervical cancer. While excessive alcohol consumption may have various health implications, moderate drinking, such as a glass of red wine with dinner, is not directly linked to an increased risk of cervical cancer.
B. Infection with certain high-risk strains of HPV is a major risk factor for cervical cancer. HPV is a sexually transmitted virus that can cause changes in cervical cells, leading to dysplasia and potentially progressing to cancer if not monitored and treated.
C. In fact, regular Pap tests are a preventive measure that can help detect cervical changes early before they develop into cancer. They are not a risk factor but rather a protective factor against the progression of cervical dysplasia to cancer.
D. While sexual history can influence HPV transmission, simply being married to the same person for an extended period does not inherently increase the risk of cervical cancer.
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