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","D","E"]
Explanation
Choice A Reason: Cloudy urine is a finding that indicates a urinary tract infection, as it shows that there are bacteria, pus, or blood in the urine.
Choice B Reason: Muscle tetany is not a finding that indicates a urinary tract infection, but it may indicate other conditions such as hypocalcemia or alkalosis.
Choice C Reason: Presence of calculi is not a finding that indicates a urinary tract infection, but it may cause or complicate a urinary tract infection by obstructing the urine flow and creating a nidus for bacterial growth.
Choice D Reason: Urinary frequency is a finding that indicates a urinary tract infection, as it shows that there is irritation and inflammation of the bladder and urethra.
Choice E Reason: Dysuria is a finding that indicates a urinary tract infection, as it shows that there is pain or burning sensation during urination.
Correct Answer is D
Explanation
Choice A Reason: Hypertension is not a common finding in a client with low calcium level, but it may indicate other conditions such as renal disease or pheochromocytoma.
Choice B Reason: Diaphoresis is not a common finding in a client with low calcium level, but it may indicate other conditions such as fever, anxiety, or hyperthyroidism.
Choice C Reason: Increased thirst is not a common finding in a client with low calcium level, but it may indicate other conditions such as diabetes mellitus, dehydration, or psychogenic polydipsia.
Choice D Reason: Muscle tetany is a common finding in a client with low calcium level, as it indicates that the nerves and muscles are overexcited and contract involuntarily. It may manifest as spasms, cramps, twitching, or tingling sensations.
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