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 D
Explanation
A. Muscle atrophy may indicate various underlying conditions but is not typically associated with an exacerbation of SLE. While it should be noted, it is not the most critical finding to report in this context.
B. Low-grade fever is a common symptom of SLE exacerbation and may not require immediate reporting unless accompanied by other concerning symptoms.
C. Joint pain is a hallmark symptom of SLE exacerbation but may not warrant immediate reporting unless it is severe or debilitating.
D. Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.
Correct Answer is B
Explanation
A. Obtaining a keyboard designed to limit wrist flexion can help minimize exacerbation of symptoms associated with carpal tunnel syndrome and not Raynaud’s phenomena.
B. Maintaining warmth is crucial for individuals with Raynaud's phenomenon because it helps prevent the onset of symptoms triggered by cold exposure or stress.Keeping the body warm, especially the extremities, helps in minimizing these vasospastic attacks by ensuring that the blood vessels remain dilated, allowing for proper blood flow.
C. While adequate vitamin D intake is important for overall health, it is not specifically indicated as a management strategy for Raynaud's syndrome.
D. Keeping both hands elevated during work breaks may provide some relief, but it may not be practical or feasible for a data entry clerk to maintain this position consistently during work hours.
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