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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Restricting sodium intake is essential in managing ascites and edema in cirrhosis, but it does not directly reduce ammonia levels. Sodium restriction is more related to fluid management rather than ammonia reduction.
B. Administering vitamin K may be necessary for correcting coagulation issues in liver disease, but it does not address the elevated ammonia levels causing encephalopathy.
C. Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms. Therefore, reducing dietary protein can help lower ammonia levels.
D. Administering diuretics is used to manage fluid retention and ascites in cirrhosis, but it does not directly impact ammonia levels. Diuretics are not the primary intervention for hepatic encephalopathy.

A. Surgical intervention B. Corticosteroid eye drops C. Antioxidant supplements, beta-carotene, and selenium D. Eyeglasses or magnifying lenses

Correct Answer is A

Explanation

A. Surgical intervention is the most common and effective treatment for age-related cataracts. Cataract surgery involves the removal of the cloudy lens and replacement with an artificial intraocular lens, which can significantly improve vision.
B. Corticosteroid eye drops are not used to treat cataracts; they are generally prescribed for reducing inflammation in various eye conditions but do not address the lens opacity caused by cataracts.
C. Antioxidant supplements, beta-carotene, and selenium have been studied for their potential role in slowing the progression of cataracts, but they are not considered a primary treatment once cataracts have developed to the point of affecting vision.
D. Eyeglasses or magnifying lenses may help improve vision temporarily in the early stages of cataracts, but they do not treat the underlying cause and are not effective in advanced cases. Surgery remains the definitive treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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