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 C

Explanation

A. Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Clients undergoing stem cell transplants are immunocompromised due to chemotherapy and conditioning regimens. To reduce the risk of infection, all equipment that comes into contact with the client, such as blood pressure cuffs, should be dedicated to that room only. This prevents cross-contamination from other patients.
D. Negative pressure rooms are for protecting others from airborne infections (e.g., TB). Stem cell transplant clients require positive pressure rooms to protect them from pathogens in the environment.

A. Send blood to the lab for a complete blood count. B. Finish the airway, breathing, circulation, disability survey. C. Assess further for a cause of the decreased circulation, D. Start normal saline fluid infusion with a large bore IV line.

Correct Answer is C

Explanation

A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.

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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

Naxlex Comprehensive Predictor Exams

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