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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Correct- As a nurse, it's important to provide accurate and helpful information to patients and families. In this situation, the parents have brought literature from a genetic counselor and are seeking clarification. The nurse should review the literature to the best of their ability and answer any questions they can. This approach demonstrates support, a willingness to help, and a commitment to providing accurate information.
B) Incorrect- While understanding the parents' reasons for seeking genetic counseling is important, it shouldn't be the first response when they have already brought literature and are seeking clarification. Addressing their questions and concerns is the immediate priority.
C) Incorrect- While it's true that the couple could contact the genetic counselor for further information, as a healthcare professional, the nurse should still offer assistance by reviewing the literature and answering questions to the best of their ability.
D) Incorrect- While support groups can be beneficial for parents of children with Trisomy 21, the immediate concern is addressing the parents' questions about the literature they've brought. Providing accurate information should be the primary focus at this time.

A. Insulin resistance B. Decreased epidermal turnover C. Pigmentation changes D. T-cell function decrease E. Polypharmacy F. Decreased subcutaneous padding

Correct Answer is ["B","D","F"]

Explanation

As people age, the turnover of skin cells decreases, resulting in slower wound healing. This can prolong the healing process and increase the risk of complications.

The immune system's function, including T-cell function, tends to decline with age.

T-cells play a crucial role in the immune response and wound healing. Decreased T-cell function can impair the body's ability to fight infection and promote efficient healing.

With aging, there is a natural loss of subcutaneous fat, which can affect wound healing. Subcutaneous fat provides padding and protection to the underlying tissues, and its reduction can increase the risk of tissue damage and delays in healing.

Insulin resistance, pigmentation changes, and polypharmacy are not directly age-related factors that impact wound healing. Insulin resistance is a condition related to impaired glucose metabolism and can affect wound healing in individuals with diabetes or other metabolic disorders, but it is not necessarily an age-related factor. Pigmentation changes and polypharmacy (the use of multiple medications) may be associated with aging but do not directly affect the physiological processes involved in wound healing.

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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)]

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

What age-related factors may factor into this client's wound healing? Select all that apply.

Correct Answer is ["B","D","F"]

Explanation

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

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The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse?

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

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)]