A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory data which reveals a platelet count of 25,000/mm3 (25 X109/L), which intervention should the nurse include in the plan of care?Reference Range

Platelets [150,000 to 400,000/mm" (150 to 400 x 109/L)]

Ensure a large gauge IV catheter is used to obtain blood samples.

Wrap bruised areas with elastic bandage dressings.

Remove cold and frozen foods from dietary trays.

Monitor urine and stool for occult blood regularly.

Answer and Explanation

The Correct Answer is D

A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient.

B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding.

C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts.

D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.

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Correct Answer is B

Explanation

A. Administer IV fluid bolus as prescribed by the healthcare provider is not the priority unless there is evidence of hypovolemia or shock, which isn't indicated by the current vital signs alone.

B. Medicate for pain and monitor vital signs according to protocol is the most important intervention. The client's elevated heart rate, respiratory rate, and blood pressure are likely due to inadequate pain control following a thoracotomy, a major surgical procedure known for causing significant postoperative pain. Managing the pain is crucial because uncontrolled pain can lead to increased sympathetic nervous system activity, resulting in tachycardia, hypertension, and tachypnea. Addressing the pain effectively will help stabilize these vital signs.

C. Encourage the client to splint the incision with a pillow to cough and deep breathe is an important postoperative intervention to prevent complications such as atelectasis, but it should be done after pain is adequately controlled, as pain can inhibit the ability to deep breathe and cough effectively.

D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter may be necessary if there are signs of hypoxia. However, the vital sign changes here are more likely related to pain rather than respiratory distress, making pain management the immediate priority.

A. Provide client teaching B. Apply oxygen via nasal cannula. C. Ask the client for a list of current medications. D. Place the client in Trendelenburg position. E. Notify the healthcare provider of the client's need for intubation. F. Administer medications as ordered.

Correct Answer is ["A","B","C","F"]

Explanation

A. Client education is also important, focusing on asthma management, the importance of carrying a non-expired inhaler, and avoiding known triggers.

B. Oxygen therapy via nasal cannula should be considered due to the patient's oxygen saturation of 88% on room air, aiming to maintain SpO2 above 94%.

C. Requesting a list of current medications is essential for reviewing potential drug interactions and ensuring comprehensive care.

D. Trendelenburg position is not indicated for this condition and could exacerbate breathing difficulties.

E. While the patient's condition should be closely monitored, the current information does not suggest an immediate need for intubation; however, the healthcare provider should be notified if the patient's condition worsens.

F. Administering medications as ordered is crucial to address the immediate respiratory distress.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

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