A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?

Determine the client's blood type.

Institute bleeding precautions.

Avoid administering IV pain medication.

Implement airborne precautions.

Answer and Explanation

The Correct Answer is B

B. Petechiae indicate a risk of bleeding due to low platelet levels or dysfunction. Bleeding precautions aim to minimize the risk of injury and bleeding events.

A While knowing the blood type is generally important for medical management, it is not the immediate priority based on the presence of petechiae alone.

C. Intravenous pain medications, especially those that can affect platelet function (like NSAIDs), may increase the risk of bleeding.

D. Airborne precautions are used for diseases transmitted by airborne droplets smaller than 5 microns, such as tuberculosis or measles. Petechiae are not indicative of an airborne disease transmission risk.

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Correct Answer is D

Explanation

D. The appropriate action would be to adjust the patient's position to restore the correct alignment and tension of the traction. This typically involves pulling the client up in bed to ensure that the weights hang freely and exert the necessary force for effective traction.

A It is not recommended to tie knots in the ropes as this action could disrupt the prescribed traction force and alignment.

B. It is helpful for other aspects of care but does not correct the traction issue caused by the weights resting on the floor.

C. This is not the correct action because it would decrease rather than increase the traction force, which is necessary for fracture alignment and healing.

A. Furosemide B. Desmopressin C. Epinephrine D. Nitroprusside

Correct Answer is B

Explanation

B. Desmopressin is a synthetic analog of vasopressin (antidiuretic hormone) that promotes water reabsorption in the kidneys, reducing urine production. It is used to treat conditions associated with excessive urination, such as diabetes insipidus or nocturnal enuresis. Since the client is experiencing excessive thirst and polyuria (excessive urine output), desmopressin would be appropriate to help reduce urine volume and manage fluid balance.

A Given the client's already high urine output, administering furosemide would further increase urine production, potentially exacerbating fluid loss and dehydration.

C. Epinephrine does not address the underlying issue of excessive thirst and polyuria related to brain injury and would not be used in this context.

D. Nitroprusside is a vasodilator that reduces blood pressure by relaxing smooth muscle in blood vessels. It is used to treat hypertensive emergencies. Nitroprusside is not relevant for addressing excessive thirst and polyuria due to brain injury.

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A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?

Nursing Test Bank

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