A nurse is assisting with the plan of care for a client who has leukemia and whose platelet count is 50,000 mm. Which of the following interventions should the nurse include in the plan of care?

Use contact precautions.

Administer ibuprofen prior to assisting with ADLS

Measure rectal temperature every 4 hr.

Administer a stool softener.

Answer and Explanation

The Correct Answer is D

A.   Leukemia itself doesn't necessitate contact precautions unless there are other specific infectious concerns, which are not mentioned in this scenario.
B.   Ibuprofen is contraindicated in patients with low platelet counts due to the risk of bleeding. Therefore, administering ibuprofen would exacerbate the risk of bleeding in this patient.
C.   Invasive procedures like rectal temperature measurements should be avoided in patients with low platelet counts due to the risk of bleeding. Thus, this intervention increases the risk of harm to the patient.
D.   Patients with low platelet counts are at risk for bleeding, including gastrointestinal bleeding. Administering a stool softener can help prevent straining during bowel movements, reducing the risk of bleeding and promoting patient comfort and safety.

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Correct Answer is C

Explanation

A. Orange, could also indicate dehydration, but it may also be caused by certain medications or foods, so it is not as specific as dark amber for dehydration.
B. Smoky urine is often associated with blood in the urine, which can result from various conditions but is not specific to dehydration.
C. Dehydration occurs when the body loses more fluids than it takes in, leading to a higher concentration of waste products in the urine, which gives it a dark amber color. This is because with less water to dilute them, the naturally occurring minerals and chemicals in the urine become more concentrated.
D. Green urine is not typically associated with dehydration and may indicate other underlying conditions or the presence of certain medications or foods.

A. Webbed areas of the fingers B. Nail beds C. Hard palate D. Peri-umbilical area

Correct Answer is C

Explanation

A. Jaundice is typically not visible in the webbed areas of the fingers.

B. The nail beds are part of the skin that can show jaundice, but they may also be aﬀected by other factors such as anemia, cyanosis, or nail polish.
C. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
D. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.

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A nurse is assisting with the plan of care for a client who has leukemia and whose platelet count is 50,000 mm. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with dehydration will have which color of urine?

Correct Answer is C

Explanation

A nurse is collecting data from a client who is African American has cholecystitis. Which of the following areas should the nurse inspect to monitor for the presence of jaundice?

Correct Answer is C

Explanation

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