A nurse is monitoring a client who is receiving chemotherapy and has a platelet count of 20,000 mm3. Which of the following findings should the nurse identify as the priority?
Fatigue
Anorexia
Bleeding
Fever
The Correct Answer is C
Choice A Reason: Fatigue is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as anemia, infection, or depression.
Choice B Reason: Anorexia is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as nausea, pain, or anxiety.
Choice C Reason: Bleeding is the priority finding for a client who has a low platelet count, as it indicates that the client is at risk of hemorrhage and shock due to impaired blood clotting.
Choice D Reason: Fever is not the priority finding for a client who has a low platelet count, but it may indicate an infection that requires prompt treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Keeping scissors at the bedside is the most important safety intervention for this client, as it allows for quick removal of the tube in case of airway obstruction or bleeding.
Choice B Reason: Providing good mouth care is an important intervention for this client, but it is not the most important, as it helps to prevent oral infections and discomfort.
Choice C Reason: Deflating the balloon on a regular basis is not an appropriate intervention for this client, as it may cause bleeding or displacement of the tube.
Choice D Reason: Monitoring IV fluid intake is an important intervention for this client, but it is not the most important, as it helps to prevent fluid overload or dehydration.
Correct Answer is C
Explanation
Choice A Reason: Fatigue is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as anemia, infection, or depression.
Choice B Reason: Anorexia is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as nausea, pain, or anxiety.
Choice C Reason: Bleeding is the priority finding for a client who has a low platelet count, as it indicates that the client is at risk of hemorrhage and shock due to impaired blood clotting.
Choice D Reason: Fever is not the priority finding for a client who has a low platelet count, but it may indicate an infection that requires prompt treatment.
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