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?
Implement airborne precautions.
Determine the client's blood type.
Institute bleeding precautions.
Avoid administering IV pain medication.
The Correct Answer is C
The nurse should institute bleeding precautions for the client.
Petechiae are small red or purple spots on the skin caused by broken capillaries, which can be a sign of low platelet count (thrombocytopenia) and an increased risk of bleeding.
Bleeding precautions include measures such as using a soft-bristled toothbrush, avoiding injections, and avoiding activities that could result in injury.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because determining the client’s blood type is not necessary in this situation.
Choice D is incorrect because avoiding IV pain medication is not necessary in this situation; however, the nurse should monitor the client for signs of bleeding and bruising.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement indicates that the nurse understands the importance of limiting the exposure of family members to radiation from the sealed implant.
Choice B is incorrect because the dosimeter badge should not be given to the oncoming nurse at the end of the shift.
The dosimeter badge is used to measure an individual’s exposure to radiation and should be worn by the same person throughout their shift.
Choice C is incorrect because if the client’s implant dislodges, the nurse should not touch it with their hands, even if they are wearing gloves.
The nurse should follow the facility’s protocol for handling dislodged implants.
Choice D is incorrect because soiled linens from a client with a sealed radiation implant do not need to be removed from the room after each change.
The linens can be handled according to standard precautions.
Correct Answer is A
Explanation
Thrombocytopenia, or low platelet count, is a contraindication to receiving heparin.
Rheumatoid arthritis is not a contraindication to receiving heparin.
Thalassemia is not a contraindication to receiving heparin.
COPD is not a contraindication to receiving heparin.
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