A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?
Check the IV site for bleeding every 8 hr
Obtain a rectal temperature every 8 hr.
Check the client for proteinuria.
Limit, IM injections.
The Correct Answer is D
A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.
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Related Questions
Correct Answer is C
Explanation
A. Humidifying the client's room helps to maintain adequate moisture levels in the air. However, it is not specifically related to low WBC counts.
B. Cleaning dentures in a denture cup and serving cooked fruit with meals are good practices for hygiene and dietary considerations but do not directly address infection control.
C. Serving cooked fruit with meals can help minimize the risk of foodborne illnesses.
D. Replacing the water in flower vases with fresh water daily is important for preventing bacterial growth but is not as directly beneficial for infection prevention in this context.
Correct Answer is D
Explanation
A. Clinical breast examinations are generally recommended every 1 to 3 years for women in their 20s and 30s and annually for women 40 and older. However, the emphasis has shifted towards mammography as a primary screening tool.
B. Routine screening for colorectal cancer typically begins at age 45 for average-risk individuals, not 40. Colonoscopies are generally recommended every 10 years if results are normal.
C. Mammograms are typically recommended to start at age 40 for average-risk women, with yearly screening starting at age 45 or 50 depending on guidelines.
D. Annual testing for fecal occult blood is a recommended screening method for colorectal cancer starting at age 45, as it helps detect blood in the stool which can be an early sign of colorectal cancer.
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