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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Morphine is effective in reducing anxiety due to its sedative and anxiolytic properties. Decreased anxiety can be an indication that morphine is effective in managing symptoms associated with acute heart failure, such as dyspnea and anxiety related to difficulty breathing.
A Morphine is a potent opioid analgesic that can depress the respiratory center, leading to decreased respiratory rate or even respiratory depression in some cases.
B. Vomiting after morphine administration does not indicate effectiveness of the medication in managing acute heart failure symptoms. It is rather a side effect that needs to be managed.
C. Decreased urinary output is not a sign of effectiveness in managing acute heart failure symptoms. It is an adverse effect that needs to be monitored and managed separately.
Correct Answer is B
Explanation
Correct choice:right infront of the ear
Rationale
Chvostek's sign is a clinical indicator of hypocalcemia (low calcium levels in the blood). It suggests increased neuromuscular irritability due to low calcium levels affecting nerve excitability.
To elicit Chvostek's sign, the examiner taps lightly over the facial nerve in front of the earlobe. A positive response is observed as twitching or spasm of the facial muscles, typically the lips, nose, and cheek on the same side.
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