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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

The age-related factors that may factor into this client's wound healing are: Decreased epidermal turnover: 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.

T-cell function decrease: 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.

Insulin resistance and pigmentation changes 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 are primarily cosmetic and do not directly affect the physiological processes involved in wound healing.

A. Inspect skin for redness. B. Use a residual limb shrinker. C. Avoid range of motion exercises. D. Apply alcohol to the residual limb after bathing.

Correct Answer is ["A","B"]

Explanation

The correct answer is a. Inspect skin for redness and b. Use a residual limb shrinker.

Choice A rationale:

Inspecting the skin for redness is crucial to identify any signs of infection or pressure sores early. Redness can indicate irritation or the beginning of a pressure ulcer, which needs to be addressed promptly to prevent further complications.

Choice B rationale:

Using a residual limb shrinker helps to reduce swelling and shape the residual limb for prosthetic fitting. It also helps in managing pain and promoting healing by providing consistent compression.

Choice C rationale:

Avoiding range of motion exercises is incorrect. Range of motion exercises are essential to maintain joint flexibility and prevent contractures, which can hinder the use of a prosthetic limb.

Choice D rationale:

Applying alcohol to the residual limb after bathing is not recommended. Alcohol can dry out the skin and cause irritation, which can lead to skin breakdown and infection. Instead, the residual limb should be kept clean and moisturized with appropriate skin care products.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

A client with diabetes insipidus (DI) has an average urinary output of 500 ml. of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

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)]