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 C
Explanation
Instruct the client to avoid eating raw fruit.
A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection.
One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
Choice D Contact isolation while providing care is not necessary for a low WBC count.
Correct Answer is D
Explanation
Lithium. Lithium is a medication that has been associated with an increased risk of developing diabetes insipidus. This is because lithium can interfere with the function of the kidneys and their ability to respond to antidiuretic hormone (ADH), which regulates the balance of fluids in the body.
Atorvastatin (choice B) is a medication used to lower cholesterol levels and has not been associated with an increased risk of diabetes insipidus.
Propranolol (choice A) is a beta-blocker used to treat high blood pressure and heart conditions and has not been associated with an increased risk of diabetes insipidus.
Ranitidine (choice C) is a medication used to reduce stomach acid production and has not been associated with an increased risk of diabetes insipidus.
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