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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Measuring body temperature is a standard procedure but not directly related to monitoring for adverse effects of prasugrel, which primarily include bleeding complications.
Choice B reason: Assessing skin turgor is generally used to evaluate hydration status and is not specific to prasugrel's adverse effects.
Choice C reason: Checking for pedal edema can indicate heart failure or vascular problems but is not a direct indicator of prasugrel's adverse effects.
Choice D reason: Observing the color of urine is important as prasugrel can cause significant and sometimes fatal bleeding. Dark or bloody urine may be an early indicator of such bleeding.
Correct Answer is C
Explanation
Choice A reason: Removing dentures or other oral appliances may be necessary for some medical procedures, but it is not the most important intervention for a client with OSA who has just received an opioid patch.
Choice B reason: Lifting and locking the side rails in place is a standard safety measure, but it does not directly address the respiratory concerns associated with OSA and opioid use.
Choice C reason: Applying the client's positive airway pressure device is the most important intervention. Opioids can depress respiration, and for a client with OSA, ensuring the airway is patent and supported by a positive airway pressure device is crucial to prevent respiratory complications.
Choice D reason: Elevating the head of the bed can aid in respiration, but it is not as immediately critical as ensuring the use of a positive airway pressure device for a client with OSA who is receiving opioids.
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