A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?
Place the client on protective isolation.
Initiate measures to prevent venous thromboembolism.
Initiate droplet precautions.
Check the client's most recent platelet level.
The Correct Answer is D
A. Protective isolation is not directly related to the symptoms of ecchymoses and petechiae but is more relevant for preventing infections in immunocompromised clients.
B. Measures to prevent venous thromboembolism are not the immediate concern given the bleeding symptoms; instead, managing platelet levels and bleeding risks is more critical.
C. Droplet precautions are not indicated based on the described symptoms, which are more related to bleeding disorders rather than infectious conditions requiring droplet precautions.
D. Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Distributive shock is associated with decreased MAP, not increased.
B. Decreased venous return occurs in distributive shock due to the pooling of blood in the periphery, leading to reduced preload and decreased cardiac output.
C. Distributive shock typically results in increased heart rate as the body attempts to compensate for decreased blood pressure and venous return.
D. Cardiac output is generally decreased in distributive shock due to reduced venous return and impaired blood flow.
Correct Answer is B
Explanation
A. Malnutrition and acute pancreatitis are not primary causes of chronic pancreatitis. While acute pancreatitis can lead to chronic conditions, malnutrition is not a common direct cause.
B. Heavy alcohol consumption and smoking are well-established risk factors for chronic pancreatitis. These lifestyle factors can cause inflammation and damage to the pancreas over time.
C. Caffeine consumption does not have a direct correlation with chronic pancreatitis. Cigarette smoking is a risk factor, but caffeine is not.
D. Acute hepatitis is not a common cause of chronic pancreatitis. While alcohol consumption is a risk factor, the presence of acute hepatitis is not typically a direct cause.
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