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 D

Explanation

A. Decreased cardiac output is not a primary concern with chlorine exposure, which primarily affects the respiratory system.
B. Hypovolemia is not directly related to chlorine gas exposure. The primary concern is respiratory damage.
C. Chronic pain is not an immediate or primary finding in chlorine gas exposure; the focus is on acute respiratory effects.
D. Pulmonary edema is a common and severe consequence of chlorine gas inhalation due to the corrosive effect of chlorine on the respiratory tract, leading to fluid accumulation in the lungs.

A. Encouraging the client to use a cane as needed for mobility B. Encouraging the client to use their right hand for daily activities C. Encouraging the client to consume a soft diet and thickened liquids D. Encouraging the client to complete all activities of daily living (ADLs) independently

Correct Answer is A

Explanation

A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.

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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

The emergency department (ED) staff has been notified of the imminent arrival of a client who has experienced respiratory exposure to the chemical agent chlorine. Which finding should the anticipate with this exposure?

Correct Answer is D

Explanation

A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

Correct Answer is A

Explanation

A nurse is caring for a client who has human immunodeficiency virus (HIV). Which of the following laboratory values would be most concerning to the nurse?

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

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?

A nurse is the triage officer in the emergency department during a disaster when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

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A nurse is teaching a client who has a new diagnosis of gout about managing the disorder. Which of the following statements by the client indicates an understanding of the teaching?

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