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
The glycosylated hemoglobin level (also known as HbA1c or A1C) is a laboratory test that reflects average levels of blood glucose over the previous two to three months.
It is the most widely used test to monitor chronic glycemic management.
Choice A is not the answer because fasting blood glucose level reflects only short-term glycemic control.
Choice C is not the answer because oral glucose tolerance test results reflect only short-term glycemic control.
Choice D is not the answer because postprandial blood glucose level reflects only short-term glycemic control.
Correct Answer is C
Explanation
The statement “These crutches will make it possible to care for my child” indicates that the client is adapting to their role change by finding ways to continue fulfilling their responsibilities despite their injury.
Choice A is incorrect because it indicates that the client is concerned about not being able to fulfill their responsibilities.
Choice B is incorrect because it indicates that the client feels guilty about not being able to fulfill their responsibilities.
Choice D is incorrect because it indicates that the client is relying on someone else to fulfill their responsibilities.
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