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 ["100"]
Explanation
IV pump rate= (Volume to be infused (mL) × 60) / Time of infusion (min).
For the given scenario, the nurse has 50 mL to infuse over 30 minutes. Using the formula, Pump rate= (50 mL × 60) / 30 min= 100 mL/hr.
Therefore, the nurse should set the IV pump to deliver 100 mL/hr.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}
Explanation
- Urine ketones:
They are commonly present in DKA due to the breakdown of fats as an alternative energy source when insulin is insufficient. Ketones in urine are a hallmark sign of DKA.
Ketones may not be present in urine in HHS because insulin levels are sufficient to prevent excessive breakdown of fats. Therefore, urine ketones are more specific to DKA.
- Creatinine greater than expected reference range
DKA: In DKA, dehydration and electrolyte imbalances can lead to acute kidney injury (AKI), resulting in elevated creatinine levels.
HHS: Elevated creatinine can also occur in HHS due to severe dehydration and reduced kidney perfusion.
- Blood glucose greater than expected reference range:
DKA: Extremely high blood glucose levels (typically >250 mg/dL) are a hallmark of DKA due to insulin deficiency and the resultant inability to transport glucose into cells for energy.
HHS: Similar to DKA, HHS is characterized by extremely high blood glucose levels (often >600 mg/dL). Therefore, elevated blood glucose levels are consistent with both DKA and HHS.
- Skin turgor
DKA: Decreased skin turgor is indicative of dehydration, which is common in DKA due to excessive urination (polyuria) and fluid loss.
HHS: Similarly, decreased skin turgor can also be seen in HHS due to profound dehydration caused by excessive hyperglycemia and osmotic diuresis.
- Blood pH greater than expected reference range
DKA: DKA is characterized by metabolic acidosis, leading to a decreased blood pH (<7.35). Therefore, a pH greater than expected reference range would not be typical for DKA.
HHS: HHS, on the other hand, is characterized by severe hyperglycemia without significant ketoacidosis. Patients with HHS can have a normal or even elevated blood pH (>7.45) due to compensation mechanisms and absence of significant acidosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.