A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?
Assess body temperature.
Monitor skin elasticity.
Observe the aspiration site.
Measure urinary output.
The Correct Answer is C
Choice A reason: Assessing body temperature is a routine post-procedure check but not the most critical for thrombocytopenia.
Choice B reason: Monitoring skin elasticity is not directly related to the risks associated with thrombocytopenia following a bone marrow biopsy.
Choice C reason: Observing the aspiration site is crucial because thrombocytopenia increases the risk of bleeding, and the site must be monitored for any signs of hemorrhage.
Choice D reason: Measuring urinary output is important but does not take precedence over monitoring the biopsy site for bleeding in a thrombocytopenic patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While developing new screening protocols is a positive step, it does not directly measure the effectiveness of the prevention program in terms of client outcomes or behavior change.
Choice B reason: Early diagnosis of at-risk clients is important, but it is a secondary measure of effectiveness that follows education and behavior change, which are primary prevention strategies.
Choice C reason: Prompt rehabilitation for clients with disease complications is a form of tertiary prevention and does not reflect the effectiveness of the primary prevention program.
Choice D reason: Improvement in client knowledge about specific risk factors as evidenced by test scores is a direct measure of the effectiveness of an educational prevention program. It indicates that clients have understood and potentially internalized the information necessary to prevent sexually transmitted diseases, which is the goal of primary prevention.
Correct Answer is D
Explanation
Choice A reason: Avoiding sunscreen is not recommended as it increases the risk of skin cancer; vitamin D can be obtained safely through diet and supplements.
Choice B reason: While it is true that vitamin D and calcium are balanced with phosphorus, this statement does not directly encourage compliance with supplementation.
Choice C reason: Although calcium uses vitamin D produced by sunlight exposure, relying solely on sunshine is not sufficient, especially for individuals at risk of osteoporosis.
Choice D reason: Emphasizing that vitamin D enhances calcium absorption into the bone provides a clear rationale for the client to comply with the supplementation regimen.
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