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.

Answer and Explanation

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.

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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.

A. Cool and shake the bottle before administering the drops. B. Insert the tip of the dropper into the canal of the ear. C. Pull the pinna up and back to administer the drops. D. Administer the drops with the head held upright.

Correct Answer is C

Explanation

Choice A reason: Cooling the bottle is not necessary and shaking it is only required if the instructions specify to do so to mix the medication.

Choice B reason: Inserting the tip of the dropper into the ear canal is not recommended as it can introduce bacteria and cause injury.

Choice C reason: Pulling the pinna up and back in adults helps to straighten the ear canal, allowing for proper delivery of the medication.

Choice D reason: Administering the drops with the head held upright is not the correct method; the head should be tilted to allow the drops to flow down into the ear canal.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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