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
A hypertensive crisis is an emergent situation in which a marked elevation in diastolic blood pressure can cause end-organ damage.
The nurse should perform neurological assessments to monitor for any changes in the patient’s level of consciousness and other neurological symptoms.
Choice A is incorrect because dopamine is not typically used to treat hypertensive crises.
Choice B is incorrect because lactated Ringer’s solution is not typically used to treat hypertensive crises.
Choice D is incorrect because placing the client supine may not be appropriate and could potentially worsen their condition.
Correct Answer is B
Explanation
The correct answer is: b. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.”
Choice A reason: Elevating the feet for long periods is not generally recommended for clients with Peripheral Arterial Disease (PAD). This is because elevation can decrease arterial blood flow to the feet, which is already compromised in PAD. The goal is to promote blood flow to the extremities, and elevation might work against this, especially if done for extended periods.
Choice B reason: Applying a lubricating lotion to the feet, particularly on the soles where the skin can become very dry and cracked, is beneficial for someone with PAD. It helps to maintain skin integrity and prevent skin breakdown, which can lead to serious complications due to the reduced blood flow and healing capacity in PAD.
Choice C reason: Soaking the feet in hot water is not advisable for individuals with PAD. They may have reduced sensation in their feet due to poor circulation, which increases the risk of burns from hot water. Additionally, prolonged soaking can lead to maceration of the skin, making it more susceptible to injury and infection.
Choice D reason: Using a heating pad, even on a low setting, to keep the feet warm is risky for clients with PAD. Due to decreased sensation from poor circulation, there is a danger of burns because the client may not feel how hot the heating pad is. It’s better to wear warm socks or use room temperature control to keep the feet warm.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today