A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?
Reference Range:
Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]
Assess urine and stool for occult blood.
Obtain client's temperature every 4 hours.
Monitor for signs of activity intolerance
Require visitors to wear respiratory masks.
The Correct Answer is A
A) Correct- With a significantly low platelet count, the risk of bleeding is elevated. Assessing urine and stool for occult (hidden) blood is important to detect any signs of internal bleeding that may not be immediately apparent. A low platelet count increases the risk of spontaneous bleeding, which can be life-threatening if undetected.
B) Incorrect- This choice is related to neutropenia, not thrombocytopenia. Neutropenia, or low neutrophil count, increases the risk of infection, which is why monitoring temperature frequently is important.
C) Incorrect- Monitoring for signs of activity intolerance is not directly related to the low platelet count. The primary concern with thrombocytopenia is the risk of bleeding, not generalized activity intolerance.
D) Incorrect- Requiring visitors to wear respiratory masks is not relevant to the client's current condition of low platelet count. This action is related to infection control and protection from respiratory infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- With a significantly low platelet count, the risk of bleeding is elevated. Assessing urine and stool for occult (hidden) blood is important to detect any signs of internal bleeding that may not be immediately apparent. A low platelet count increases the risk of spontaneous bleeding, which can be life-threatening if undetected.
B) Incorrect- This choice is related to neutropenia, not thrombocytopenia. Neutropenia, or low neutrophil count, increases the risk of infection, which is why monitoring temperature frequently is important.
C) Incorrect- Monitoring for signs of activity intolerance is not directly related to the low platelet count. The primary concern with thrombocytopenia is the risk of bleeding, not generalized activity intolerance.
D) Incorrect- Requiring visitors to wear respiratory masks is not relevant to the client's current condition of low platelet count. This action is related to infection control and protection from respiratory infections.
Correct Answer is ["B","D"]
Explanation
A) Incorrect- This behavior is not safe for maintaining balance. Bending from the waist can increase the risk of falling. Clients should bend at the knees and use proper body mechanics to pick up objects from the floor.
B) Correct- Widening the stance provides a broader base of support, which can help improve balance and stability while working near the sink. This is a safe behavior to maintain balance.
C) Incorrect- Locking the knees while standing can lead to instability and decreased balance. It is recommended to keep the knees slightly flexed to maintain better balance.
D) Correct- Bringing a heavy object close to the body before lifting minimizes strain on the back and helps maintain balance. This is a safe behavior when lifting objects.
E) Incorrect- Leaning forward to pull an object from a high shelf can disrupt the center of balance and increase the risk of falling. It's important to use a step stool or ask for assistance when reaching for items on high shelves.
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