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 D

Explanation

Choice A Reason: Calling the RN supervisor is not the priority action for the nurse, as it may delay the intervention and outcome.

Choice B Reason: Completing an incident report is not the priority action for the nurse, as it does not address the immediate problem or prevent further complications.

Choice C Reason: Checking the blood glucose level is not the priority action for the nurse, as it may confirm the error but not correct it.

Choice D Reason: Giving the client 15 to 20 g of carbohydrate is the priority action for the nurse, as it may prevent or treat hypoglycemia, which is a serious complication of insulin overdose.

A. Urine output 800 mL/hr B. Blood glucose 198 mg/dL C. Serum sodium 145 mEq/L D. Urine specific gravity 1.028

Correct Answer is A

Explanation

Choice A Reason: Urine output 800 mL/hr is a sign of diabetes insipidus, as it indicates that the kidneys are producing large amounts of diluted urine due to the lack of antidiuretic hormone (ADH) or its action.

Choice B Reason: Blood glucose 198 mg/dL is not a sign of diabetes insipidus, but it may indicate diabetes mellitus or hyperglycemia.

Choice C Reason: Serum sodium 145 mEq/L is not a sign of diabetes insipidus, but it is within the normal range (135-145 mEq/L).

Choice D Reason: Urine specific gravity 1.028 is not a sign of diabetes insipidus, but it indicates concentrated urine due to dehydration or other causes.

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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

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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