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 C
Explanation
Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.
Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.
Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.
Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.
Correct Answer is A
Explanation
Choice A reason: The priority is to manage the client's severe pain, which can be achieved through the administration of an IV analgesic. Effective pain management is crucial for postoperative recovery and can prevent complications related to increased pain, such as elevated heart rate and blood pressure.
Choice B reason: While assessing the IV site for patency is important, it is not the most critical intervention when a client is experiencing severe pain.
Choice C reason: Providing a pillow for splinting can help with pain management during movement or coughing but does not directly address the immediate need for pain relief.
Choice D reason: Placing the client in a high-Fowler's position may aid in comfort and breathing but is not the most important intervention for severe pain management.

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