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. A client who has a compound fracture of the right femur B. A client who reports having fever, night sweats, and cough for 2 days C. An older adult client who was admitted with aspiration pneumonia D. A client who has diabetes mellitus and is presenting with acute ketoacidosis

Correct Answer is B

Explanation

B. Respiratory infections can spread via droplets, necessitating airborne precautions and isolation in a private negative pressure room to prevent transmission to other clients and healthcare workers.

A A compound fracture involves an open wound where the bone has punctured the skin. While this client may require isolation precautions due to the open wound, the primary concern is not infectious in nature.

C. Aspiration pneumonia can be caused by inhalation of oral or gastric contents into the lungs, leading to infection. Therefore, such a client does not require isolation.

D Acute ketoacidosis in diabetes mellitus is a metabolic emergency but is not typically contagious or requiring isolation precautions for infection control.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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