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 D
Explanation
Choice A Reason: Ketoacidosis is not likely to be the complication that the nurse should suspect, as it is caused by high blood glucose levels and results in symptoms such as nausea, vomiting, abdominal pain, fruity breath, and deep breathing.
Choice B Reason: Hyperglycemia is not likely to be the complication that the nurse should suspect, as it is caused by high blood glucose levels and results in symptoms such as thirst, polyuria, blurred vision, dry skin, and fatigue.
Choice C Reason: Nephropathy is not likely to be the complication that the nurse should suspect, as it is a chronic kidney disease that develops over time due to diabetes and results in symptoms such as proteinuria, edema, hypertension, and anemia.
Choice D Reason: Hypoglycemia is likely to be the complication that the nurse should suspect, as it is caused by low blood glucose levels and results in symptoms such as sweating, tachycardia, lightheadedness, shakiness, hunger, and confusion.
Correct Answer is C
Explanation
Choice A Reason: Encouraging deep-breathing exercises is not the most appropriate nursing intervention, as it may not reduce fatigue and may increase respiratory effort.
Choice B Reason: Providing a relaxing warm bath is not the most appropriate nursing intervention, as it may worsen fatigue and increase the risk of heat intolerance and dehydration.
Choice C Reason: Scheduling periods of rest in between activities is the most appropriate nursing intervention, as it helps to conserve energy, prevent exhaustion, and promote recovery.
Choice D Reason: Administering multivitamins is not the most appropriate nursing intervention, as it may not improve fatigue and may cause adverse effects or interactions with other medications.
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