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 C

Explanation

C. This action demonstrates advocacy by ensuring the client has access to necessary support services that can help them maintain independence and receive adequate care in their home environment.

A Reminding the client about medication adherence is important for the client's health management, but they do not directly advocate for the client's autonomy and support system.

B. While this advice is prudent for reducing infection risk, it may limit the client's social interactions and independence. Advocacy involves balancing health promotion with the client's autonomy and quality of life.

D. Raw vegetables may carry a risk of foodborne infections, which can be more severe for individuals with compromised immune systems, such as those with AIDS.

A. Postprandial blood glucose level B. Glycosylated hemoglobin level C. Fasting blood glucose level D. Oral glucose tolerance test results

Correct Answer is B

Explanation

B. HbA1c is considered the gold standard for assessing long-term glycemic control in individuals with diabetes. It provides an overall picture of how well blood sugar levels have been controlled over the preceding 2-3 months, helping healthcare providers adjust treatment plans as needed.

A Postprandial (after-meal) blood glucose levels indicate how well blood sugar levels are controlled after eating. While important for immediate assessment of glucose management after meals, it does not provide a comprehensive view of long-term glycemic control.

C. While fasting blood glucose levels are important in daily diabetes management, they do not provide the extended timeframe assessment that HbA1c does for long-term control.

D. OGTT results are not typically used to monitor long-term glycemic control in individuals with established diabetes mellitus. It assesses how the body responds to a glucose load and is not as practical or common for routine monitoring compared to HbA1c.

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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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