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
The nurse should plan to notify the Rapid Response Team first.
The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low.
These are all signs of potential instability and the Rapid Response Team should be notified immediately.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.
Correct Answer is A
Explanation
Let’s break down the problem step by step:
Step 1: Convert the client’s weight from pounds (lb) to kilograms (kg). We know that 1 kg = 2.2 lbs. So, we have: 220 lb ÷ 2.2 = 100 kg
Step 2: Calculate the total amount of naloxone needed. The doctor ordered 10 mcg/kg, and the client weighs 100 kg. So, we have: 10 mcg/kg × 100 kg = 1000 mcg
Step 3: Convert micrograms (mcg) to milligrams (mg). We know that 1 mg = 1000 mcg. So, we have: 1000 mcg ÷ 1000 = 1 mg
Step 4: Calculate the volume of naloxone solution needed. The available naloxone solution is 0.4 mg/mL. So, we have: 1 mg ÷ 0.4 = 2.5 mL
So, the nurse should administer 2.5 mL of naloxone. Since we are asked to round off to the nearest tenth, the final answer remains 2.5 mL.
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