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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

Answer and Explanation

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).

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Correct Answer is C

Explanation

A. The patient states having nasal congestion. – Incorrect. Nasal congestion is a symptom of autonomic dysreflexia, not a trigger.

B. The patient’s blood pressure becomes elevated. – Incorrect. Hypertension is a symptom of autonomic dysreflexia, not the cause.

C. The patient’s bladder becomes distended. – Correct Answer. Bladder distention is the most common trigger of autonomic dysreflexia, a life-threatening condition causing sudden hypertension, bradycardia, and severe headache. Immediate intervention is needed, such as catheterizing the bladder.

D. The patient states having a severe headache. – Incorrect. A severe headache is a symptom of autonomic dysreflexia, not a cause.

A. Impaired immunity B. Hypoxia C. Fluid retention D. Prolonged bleeding

Correct Answer is B

Explanation

A. Impaired immunity. – Incorrect. While anemia may weaken overall health, hemoglobin levels of 10 g/dL do not significantly affect immune function.

B. Hypoxia. – Correct Answer. Hemoglobin carries oxygen in the blood, and low levels can lead to decreased oxygen delivery to tissues, causing hypoxia.

C. Fluid retention. – Incorrect. Anemia does not directly cause fluid retention.

D. Prolonged bleeding. – Incorrect. While severe anemia can be associated with bleeding disorders, a hemoglobin level of 10 g/dL does not significantly impair clotting.

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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?

Nursing Test Bank

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