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. Swab teeth and mucous membranes four times daily with lemon-glycerin swabs B. Brush teeth twice a day with a firm toothbrush C. Use sponge Toothettes to clean teeth between meals D. Use waxed floss between meals and at bedtime

Correct Answer is C

Explanation

A. Lemon-glycerin swabs can dry out and irritate oral tissues, increasing the risk of oral mucositis and infection.
B. Using a firm toothbrush may be too harsh for irritated mucous membranes and can increase the risk of injury and bleeding.
C. Gentle oral care is essential to avoid further irritation of the mucous membranes.

D. Flossing may be too abrasive for irritated mucous membranes and can increase the risk of bleeding and injury.

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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?

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