A nurse is contributing to the plan of care for a client who has thrombocytopenia due to chemotherapy. Which of the following interventions should the nurse include?
Avoid IM injections.
Obtain a rectal temperature once per shift.
Do not allow the client to have visitors.
Encourage daily flossing between teeth.
The Correct Answer is A
Choice A reason: This is the correct intervention, because avoiding IM injections can prevent bleeding and hematoma formation in the client who has low platelet count and impaired clotting.
Choice B reason: This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.
Choice C reason: This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.
Choice D reason: This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.
Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.
Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.
Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.
Correct Answer is C
Explanation
Choice A reason: A cholesterol level of 195 mg/dL is not an increased risk for atherosclerosis, because it is within the normal range of less than 200 mg/dL. Cholesterol is a type of fat that circulates in the blood and can contribute to plaque formation in the arteries.
Choice B reason: Elevated HDL levels are not an increased risk for atherosclerosis, because HDL stands for high-density lipoprotein, which is the "good" cholesterol that helps to remove excess cholesterol from the blood and prevent plaque formation in the arteries.
Choice C reason: Elevated LDL levels are an increased risk for atherosclerosis, because LDL stands for low-density lipoprotein, which is the "bad" cholesterol that can deposit in the arterial walls and cause plaque formation and narrowing of the arteries.
Choice D reason: A triglyceride level of 135 mg/dL is not an increased risk for atherosclerosis, because it is within the normal range of less than 150 mg/dL. Triglycerides are another type of fat that circulates in the blood and can contribute to plaque formation in the arteries.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.