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 D

Explanation

A. While using salt, herbs, and spices may enhance the flavor of foods, it does not specifically relate to self-management of type 2 diabetes mellitus.

B. Restricting alcoholic beverages is important in diabetes management, but the frequency and quantity recommended may vary based on individual factors and should be discussed with a healthcare provider.

C. Eating a protein snack before exercise can help stabilize blood sugar levels, but it should be consumed before and after exercise, not only before, to provide sustained energy.

D. Getting an influenza vaccine every year is a crucial aspect of diabetes self- management, as people with diabetes are at increased risk of complications from influenza. This demonstrates understanding of the importance of preventive care in managing diabetes.

A. Discontinue infusing solution. B. Irrigate the catheter manually. C. Monitor catheter drainage. D. Decrease the flow rate.

Correct Answer is C

Explanation

A. Discontinuing the infusion of the solution may compromise the effectiveness of continuous bladder irrigation, which is typically indicated after TURP to prevent clot retention and ensure urinary drainage.

B. Manual irrigation of the catheter may disrupt the established irrigation system and lead to further complications. It is not the initial action to take in this situation.

C. Monitoring catheter drainage allows the nurse to assess the effectiveness of bladder irrigation and the presence of clot formation. Continued observation is necessary to ensure adequate drainage and identify any signs of complications.

D. Decreasing the flow rate may not address the underlying issue of clot retention and may not be appropriate without further assessment of the client's condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently bum and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)