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 B
Explanation
This statement indicates that the client understands that genital herpes lesions can take time to heal and that they may not resolve immediately.
Choice A is incorrect because antibiotic ointment is not used to treat genital herpes lesions.
Antiviral medication is used to manage symptoms and prevent outbreaks.
Choice C is incorrect because natural skin condoms are not effective in preventing the spread of genital herpes.
Latex condoms should be used during sexual intercourse to reduce the risk of transmission.
Choice D is incorrect because the duration of antiviral medication treatment for genital herpes varies and may be longer than 3 weeks.
It’s important for the client to follow their healthcare provider’s instructions for taking medication.
Correct Answer is B
Explanation
After inhaling deeply using an incentive spirometer, you should hold your breath for 3 to 5 seconds before exhaling.
Choice A is wrong because exhaling slowly through pursed lips is not an instruction for using an incentive spirometer.
Choice C is wrong because placing hands on the upper abdomen during inhalation is not an instruction for using an incentive spirometer.
Choice D is wrong because positioning the mouthpiece.5 cm (1 in) from the mouth is not an instruction for using an incentive spirometer.
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