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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Applying calamine lotion can provide relief from itching but does not address potential complications such as swelling or allergic reactions.
B. Applying ice packs can help reduce swelling and pain, but it is not the priority action in this scenario.
C. Attempting to remove the patient's rings is crucial to prevent complications such as restricted blood flow due to swelling, which can be exacerbated by bee stings. However, this should be done after administering diphenhydramine.
D. The nurse should first administer diphenhydramine (Benadryl) 50 mg PO to counteract the effects of the bee venom and reduce the risk of anaphylaxis.

A. Mental status assessment B. Nutritional assessment C. An environmental health assessment D. Faith based assessment

Correct Answer is C

Explanation

A. Mental status assessment involves evaluating a client's cognitive and emotional function.
B. Nutritional assessment involves evaluating a client's dietary intake and nutritional status.
C. An environmental health assessment involves assessing exposure to environmental hazards such as chemicals and pollutants.
D. Faith-based assessment involves exploring a client's religious or spiritual beliefs and practices.

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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?

Nursing Test Bank

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