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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","F","J"]
Explanation
A. Garlic is generally considered safe for individuals with gout.
B. Organ meats like liver are very high in purines and should be avoided in a diet for managing gout.
C. Spinach contains moderate amounts of purines, but newer research suggests that they may not increase the risk of gout attacks as much as once thought, and they provide other health benefits that can be weighed in dietary decisions.
D. Oatmeal is generally considered safe for individuals with gout.
E. Chicken is generally considered safe for individuals with gout.
F. Seafood, particularly shellfish like shrimp, is also high in purines and generally recommended to be limited or avoided in a gout diet.
G. Lentils contain moderate amounts of purines, but newer research suggests that they may not increase the risk of gout attacks as much as once thought, and they provide other health benefits that can be weighed in dietary decisions.
H. Quinoa is generally considered safe for individuals with gout.
I. Oranges is generally considered safe for individuals with gout.
J. Small oily fish such as sardines are another source of high purines and are often advised against in the diet of someone managing gout.
Correct Answer is A
Explanation
A. Crohn's disease with colectomy. Peritoneal dialysis involves instilling dialysis fluid into the peritoneal cavity, and conditions that affect the integrity or function of the peritoneum, such as Crohn's disease with colectomy, can be contraindications due to the risk of infection or inadequate dialysis.
B. Latent hepatitis C is not a contraindication for peritoneal dialysis, although active hepatitis C infection may be a concern due to increased risk of peritonitis.
C. Type 2 diabetes mellitus is not a contraindication for peritoneal dialysis; in fact, it is a common cause of end-stage renal disease and may necessitate dialysis.
D. Nephrotic syndrome history is not a contraindication for peritoneal dialysis; in fact, peritoneal dialysis may be indicated in some cases of renal failure associated with nephrotic syndrome.
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