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: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.
Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.
Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.
Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.
Correct Answer is C
Explanation
Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.
Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.
Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.
Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.
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