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.
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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Related Questions
Correct Answer is C
Explanation
C. This statement shows understanding of precautions to prevent exposure to toxoplasmosis, a common opportunistic infection in individuals with compromised immune systems, including those with AIDS. Toxoplasmosis can be transmitted through handling cat feces.
A This statement suggests a general intention to improve nutrition, which is beneficial for overall health but does not specifically address infection control or prevention of opportunistic infections related to AIDS. While a healthy diet supports immune function indirectly, it does not directly demonstrate understanding of specific precautions needed due to AIDS.
B. This statement reflects a misunderstanding because HIV (Human Immunodeficiency Virus), which causes AIDS, does not survive long outside the body and cannot be transmitted through clothing.
Sterilizing clothes at a dry cleaner is unnecessary for preventing the spread of HIV.
D HIV can be effectively killed with regular household cleaners (such as bleach solutions), but alcohol alone may not be sufficient. Proper disposal of contaminated materials is important, but the method described does not accurately reflect infection control measures for HIV.
Correct Answer is D
Explanation
D. Instructing the client not to bend the affected leg helps prevent accidental dislodgement of the arterial sheath or catheter and reduces the risk of bleeding or hematoma formation at the insertion site.
A While monitoring vital signs is important, doing so once every hour is not specified as a standard post- procedure action.
B. Elevating the head of the bed to a 45° angle and restricting fluid intake are not standard care measures following this procedure and could potentially be contraindicated.
C. This action is not typically necessary following a cardiac catheterization unless there are specific indications such as fluid overload or impaired renal function
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