A nurse is admitting a 56-year old male patient who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?
Neutropenic
Contact
Droplet
Bleeding
The Correct Answer is D
A. Neutropenic – Used for low WBC count, not platelets.
B. Contact – Used for infections like C. diff or MRSA.
C. Droplet – Used for respiratory illnesses like flu or meningitis.
D. Bleeding – Correct Answer. A low platelet count increases the risk of bleeding, so bleeding precautions are necessary (e.g., soft toothbrush, avoiding IM injections, fall precautions).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Check the patient’s blood temperature. – Correct Answer. A headache and stiff neck are classic signs of meningitis. Fever is another key symptom, so checking temperature helps confirm suspicion and guides urgent intervention.
B. Administer an oral analgesic. – Incorrect. Pain management is secondary. The priority is assessing for infection (meningitis).
C. Perform a complete blood count. – Incorrect. While a CBC may show elevated WBCs, immediate assessment is more urgent.
D. Evaluate the patient’s neurological status. – Incorrect. While neurological assessment is important, confirming fever as an infection indicator is the first step.
Correct Answer is A
Explanation
A. Correct. The GCS assesses level of consciousness based on eye-opening, verbal response, and motor response.
B. Incorrect. Reflex activity is assessed separately using neurological reflex tests.
C. Incorrect. Sensory involvement is evaluated through different neurological exams, not the GCS.
D. Incorrect. Cognitive ability assessment requires specialized tests, such as the Mini-Mental State Examination (MMSE).
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