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 A

Explanation

A. Levothyroxine is a thyroid hormone replacement used to treat hypothyroidism. Symptoms such as tremors, nervousness, and insomnia can indicate that the dose is too high, as these are signs of hyperthyroidism.
B. Weight loss is not a typical reason to notify the healthcare provider unless it is accompanied by other symptoms of hyperthyroidism. Monitoring for symptoms of excessive thyroid hormone can be more critical.
C. Levothyroxine does not typically require monitoring for an increased risk of bleeding. This medication primarily affects thyroid hormone levels and does not have a direct impact on blood clotting.
D. Levothyroxine increases, rather than decreases, thyroid hormone levels. It is used to replace or supplement thyroid hormone in the case of hypothyroidism, not to decrease thyroid hormone production.

A. Time of the burn B. Depth of the burn C. Cause of the burn D. Location of the burn

Correct Answer is B

Explanation

A. The time of the burn helps in understanding how long the client has been exposed and may influence the assessment of burn progression, but it does not directly determine the severity.
B. The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.
C. The cause of the burn is important for treatment considerations and understanding the mechanism of injury but does not impact the assessment of burn severity.
D. The location of the burn affects the potential for complications and functional impairment but is secondary to the depth in determining overall burn severity.

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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

A nurse is providing education about levothyroxine to a client diagnosed with primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

Correct Answer is A

Explanation

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Correct Answer is B

Explanation

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