A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions?

Spontaneous bleeding

Infection

Oliguria

Hyperactive deep tendon reflexes

Answer and Explanation

The Correct Answer is A

A.   Thrombocytopenia (low platelet count) predisposes the client to spontaneous bleeding. This can manifest as petechiae (small red or purple spots on the skin), purpura (larger areas of purple discoloration), mucosal bleeding (such as nosebleeds or bleeding gums), or internal bleeding (such as gastrointestinal or intracranial bleeding). Monitoring for signs of bleeding is essential to promptly intervene and prevent complications.
B.   While infections can occur in any client, a low platelet count does not directly predispose the client to infection. Thrombocytopenia primarily affects hemostasis rather than immune function.
C.   Oliguria refers to decreased urine output, typically less than 400 mL/day in adults. It is not directly related to thrombocytopenia but may occur in conditions affecting kidney function or fluid balance.
D.   Hyperactive deep tendon reflexes can indicate neurological conditions or electrolyte imbalances but are not associated with thrombocytopenia.

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Correct Answer is B

Explanation

A. This statement suggests symptoms of vitamin B12 deficiency or glossitis, which are not typical signs of digoxin toxicity. Therefore, it is unlikely to indicate digoxin toxicity.
B. Blurred vision is a common neurological symptom of digoxin toxicity. It occurs due to disturbances in visual acuity and color vision, which can manifest as seeing halos around lights or difficulty focusing. Therefore, this statement is indicative of potential digoxin toxicity.
C. Weight gain can occur due to fluid retention, which is a symptom of heart failure rather than digoxin toxicity. Digoxin toxicity typically presents with neurological and gastrointestinal symptoms rather than weight gain.
D. Constipation is not typically associated with digoxin toxicity. Gastrointestinal symptoms such as nausea, vomiting, and anorexia are more common with digoxin toxicity, but constipation is not a specific indicator.

A. Assess the airway. B. Administer prescribed bronchodilators. C. Administer prescribed mucolytics. D. Provide oxygen.

Correct Answer is A

Explanation

A. Assessing the airway is always a priority in any client care situation, especially when there are respiratory abnormalities such as respiratory acidosis. Ensuring a patent airway is crucial to maintain adequate oxygenation and ventilation.
B. Bronchodilators are typically used to treat conditions such as bronchoconstriction in asthma or chronic obstructive pulmonary disease (COPD). However, in the context of respiratory acidosis with an elevated PaCO2, the primary issue is not bronchoconstriction but rather impaired gas exchange due to inadequate ventilation.
C. Mucolytics are medications used to thin mucus and facilitate its removal from the respiratory tract. While they can be beneficial in conditions with thick secretions, they do not address the underlying cause of respiratory acidosis, which is inadequate CO2 elimination.
D. Providing oxygen can help improve oxygenation in clients with respiratory acidosis. However, it is important to note that oxygen alone will not correct the underlying cause of respiratory acidosis (elevated PaCO2). Oxygen therapy is supportive and helps to improve oxygen delivery to tissues while other interventions are addressed.

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A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?

Correct Answer is B

Explanation

A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.1, PaCO2 70 mm Hg, and HCO3 22 mEq/L. Which intervention does the nurse implement first?

Correct Answer is A

Explanation

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The nurse is caring for a client with a heart rate of 48. His blood pressure is 120/80. Which finding will help the nurse determine the cause of the client's bradycardia?

A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions?

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