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 B
Explanation
B. Changes in the fluid level of the water-seal chamber correspond to the client's breathing pattern. During inhalation, the negative pressure in the chest cavity may cause the fluid level to rise slightly as air is drawn into the tube, and during exhalation, the fluid level may fall as air exits through the chest tube.
A Fluctuations in the fluid level can occur due to changes in suction pressure settings, but this is more relevant to the suction control chamber rather than the water-seal chamber.
C. If there is continuous bubbling in the water-seal chamber, it indicates an air leak, which disrupts the normal function of the water-seal mechanism.
D. The water-seal chamber's fluctuation does not directly indicate lung re-expansion. Lung re-expansion is assessed through clinical examination, chest X-ray, or other diagnostic tests rather than the water-seal chamber.
Correct Answer is B
Explanation
B. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.
A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.
C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.
D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning
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