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: Cushing's is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excess cortisol and aldosterone production.

Choice B Reason: Diabetes insipidus is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive water loss and dilution of blood.

Choice C Reason: Addison's is an expected health problem in a client with high potassium level, as it causes high potassium level due to insufficient cortisol and aldosterone production.

Choice D Reason: Diarrhea is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive fluid and electrolyte loss.

A. Contact the health care provider. B. Administer PRN pain medication. C. Document the findings. D. Elevate the extremity.

Correct Answer is A

Explanation

Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.

Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.

Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.

Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.

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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

A nurse notes that a client's serum potassium level is 6 mEq/L. The nurse interprets this as an expected finding in the client with which health problem?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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