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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Taking salt tablets can lead to electrolyte imbalances and is not recommended for managing heat-related issues.
B. Drinking extra fluids helps prevent dehydration and is an effective measure to prevent heat-related illness.
C. Moving to a cool environment when feeling confused is important but is a reactive measure rather than preventive teaching.
D. Taking acetaminophen for feeling too warm does not address the underlying issue of heat-related illness and is not appropriate discharge teaching for this situation.
Correct Answer is ["5"]
Explanation
To calculate the infusion time for a 1-L bag of 0.9% sodium chloride at a rate of 200 mL/hr, you would divide the total volume of the IV bag by the hourly infusion rate. Since there are 1000 mL in a 1-L bag, you would calculate 1000 mL divided by 200 mL/hr, which equals 5 hours.
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