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 A
Explanation
A. Hypovolemic shock is characterized by low blood pressure, pale skin, and abdominal pain due to significant fluid loss or hemorrhage. The client's symptoms, including hypotension and abdominal pain, suggest a reduction in blood volume potentially caused by gastrointestinal bleeding or ulceration, which is consistent with chronic aspirin use.
B. Obstructive shock is due to a physical obstruction of blood flow, such as a pulmonary embolism or cardiac tamponade, which does not directly correlate with the client's presentation of symptoms.
C. Cardiogenic shock results from severe heart failure and is typically accompanied by signs of heart dysfunction, not just low blood pressure and abdominal pain.
D. Septic shock is associated with infection and systemic inflammation, often presenting with fever and other signs of infection, which the client is not exhibiting.
Correct Answer is ["11.074"]
Explanation
To calculate the infusion rate, we'll use the following formula:
Infusion rate (mL/hr) = Desired dose (units/hr) / Concentration of heparin (units/mL)
First, calculate the desired dose in units/hr:
- 14 units/kg/hr x 79.1 kg = 1107.4 units/hr
Next, calculate the concentration of heparin in the IV bag:
- 25,000 units / 250 mL = 100 units/mL
Finally, plug the values into the formula:
- Infusion rate = 1107.4 units/hr / 100 units/mL = 11.074 mL/hr
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