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 D

Explanation

A. Postoperative pain typically resolves after a laparoscopic cholecystectomy since the surgery removes the gallbladder
B. While positioning during surgery can cause discomfort, isolated right shoulder pain is more commonly attributed to the diaphragmatic irritation from residual nitrous oxide in the abdomen.

C. Nitrous dioxide used during laparoscopic procedures is not associated with referred pain to the right shoulder. The pain is due to carbon dioxide gas used during the procedure resulting in the irritation of the diaphragm.
D. This pain is often due to the carbon dioxide used to inflate the abdomen during surgery, which can irritate the diaphragm and refer pain to the shoulder. Ambulation helps to absorb the gas more quickly.

A. Defibrillation B. Antiarrhythmic medication C. Synchronized cardioversion D. Pacemaker

Correct Answer is A

Explanation

A. Pulseless ventricular tachycardia requires immediate defibrillation to restore a perfusing rhythm.
B. Antiarrhythmic medications are not typically effective for pulseless ventricular tachycardia as the heart is not effectively pumping blood.
C. Synchronized cardioversion is used for certain tachyarrhythmias with a pulse but is not appropriate for pulseless ventricular tachycardia.
D. A pacemaker is not indicated for pulseless ventricular tachycardia as it does not address the underlying issue of cardiac arrest.

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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 nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

The nurse responds to a call for assistance with a patient in pulseless ventricular tachycardia. The nurse prepares for what first-line treatment for this rhythm?

Correct Answer is A

Explanation

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