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: Children's aspirin is not recommended due to the risk of Reye's syndrome and is not typically used for post-vaccination care.

Choice B reason: While fever can occur after vaccination, not all fevers are serious and can often be managed at home unless they are high or persistent.

Choice C reason: Keeping the child home from daycare is not necessary unless the child is feeling unwell or has a fever.

Choice D reason: Applying a cool pack to the injection site is a common recommendation to reduce discomfort and swelling after vaccinations.

A. Report any change in urine color. B. Maintain in high Fowler's position. C. Keep mucous membranes moist. D. Record the client's daily weights.

Correct Answer is C

Explanation

Choice A reason: Reporting any change in urine color is important but not specific to the provision of palliative care at home.

Choice B reason: Maintaining in high Fowler's position is not always necessary and may not be comfortable for all clients, especially in a palliative care setting.

Choice C reason: Keeping mucous membranes moist helps prevent discomfort and is a key part of providing compassionate end-of-life care.

Choice D reason: Recording the client's daily weights is less relevant in palliative care, where the focus is on comfort rather than ongoing medical assessments.

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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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