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 B

Explanation

A. While the time of the burn can provide information about the potential progression of injury, it is not the primary factor in determining the severity of the burn.
B. The depth of the burn is crucial for assessing the severity of the injury as it directly impacts the treatment required and the potential for complications. Depth determines whether the burn is superficial, partial-thickness, or full-thickness.
C. The cause of the burn is relevant for understanding the mechanism of injury but does not directly affect the assessment of burn severity.
D. The location of the burn is important for assessing potential complications and functional impairment but is secondary to the depth of the burn when determining overall severity.

Correct Answer is ["31.5%"]

Explanation

Anterior trunk 18%

Left arm 9%

Right forearm 4.5%

Total = 18+9+4.5= 31.5%

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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 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

Correct Answer is ["31.5%"]

Explanation

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