A client on the oncology unit is receiving a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. For which symptom should the nurse assess in clients at risk for thrombocytopenia?

Petechiae

Decreased white blood cell count

Increased fatigue

Unexplained bone pain

Answer and Explanation

The Correct Answer is A

A. Petechiae are small, red or purple spots on the skin that indicate bleeding under the skin and are a classic sign of thrombocytopenia, a condition characterized by a low platelet count.
B. A decreased white blood cell count is more indicative of leukopenia, not thrombocytopenia. Thrombocytopenia specifically affects platelet counts.
C. Increased fatigue can be a symptom of many conditions but is not specific to thrombocytopenia. It may occur due to anemia or other side effects of chemotherapy.
D. Unexplained bone pain is not a typical symptom of thrombocytopenia. It might be related to other conditions or side effects but is not specific to low platelet counts.

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Correct Answer is C

Explanation

A. Restricting sodium intake is essential in managing ascites and edema in cirrhosis, but it does not directly reduce ammonia levels. Sodium restriction is more related to fluid management rather than ammonia reduction.
B. Administering vitamin K may be necessary for correcting coagulation issues in liver disease, but it does not address the elevated ammonia levels causing encephalopathy.
C. Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms. Therefore, reducing dietary protein can help lower ammonia levels.
D. Administering diuretics is used to manage fluid retention and ascites in cirrhosis, but it does not directly impact ammonia levels. Diuretics are not the primary intervention for hepatic encephalopathy.

A. Inject the insulin 15-30 minutes before a meal. B. Assess for hypoglycemia 4 hrs. after the insulin injection. C. Monitor for an increase in appetite. D. Administer with insulin glargine in the same syringe.

Correct Answer is A

Explanation

A. Insulin lispro is a rapid-acting insulin that should be administered 15-30 minutes before a meal to manage blood glucose levels effectively. This timing helps to match the peak action of the insulin with the rise in blood glucose levels after eating.
B. Hypoglycemia from insulin lispro typically occurs within 1-3 hours of administration, not 4 hours later. Regular monitoring during this time frame is more appropriate.
C. An increase in appetite is not a direct result of insulin lispro administration and does not indicate insulin effectiveness or safety.
D. Insulin lispro and insulin glargine should not be mixed in the same syringe as they have different action profiles and pH levels, which can affect their efficacy.

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A client on the oncology unit is receiving a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. For which symptom should the nurse assess in clients at risk for thrombocytopenia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Correct Answer is C

Explanation

A nurse is preparing to administer insulin lispro to a client who has diabetes mellitus type 1. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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