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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason: Placing an ice pack on the lips if they swell is not an appropriate instruction for a client who is taking allopurinol, as it may indicate an allergic reaction or angioedema, which requires immediate medical attention.

Choice B Reason: Using an OTC antihistamine lotion if a rash develops is not an appropriate instruction for a client who is taking allopurinol, as it may indicate a serious skin reaction such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which requires immediate medical attention.

Choice C Reason: Drinking at least 8 glasses of fluid every day is an appropriate instruction for a client who is taking allopurinol, as it helps to prevent kidney stones and flush out uric acid from the body.

Choice D Reason: Taking the medication on an empty stomach 2 hours before meals is not an appropriate instruction for a client who is taking allopurinol, as it may cause stomach upset or nausea. The medication should be taken after meals with plenty of water.

A. Hypertension B. Fluid retention C. Elevated blood glucose D. Increased urine output

Correct Answer is D

Explanation

Choice A Reason: Hypertension is not a common finding in diabetes insipidus, but it may indicate increased intracranial pressure or other complications.

Choice B Reason: Fluid retention is not a common finding in diabetes insipidus, but it may indicate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or heart failure.

Choice C Reason: Elevated blood glucose is not a common finding in diabetes insipidus, but it may indicate diabetes mellitus or hyperglycemia.

Choice D Reason: Increased urine output is a common finding in diabetes insipidus, as the lack of antidiuretic hormone (ADH) causes the kidneys to excrete large amounts of diluted urine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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