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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Metabolic acidosis is characterized by a low pH (<7.35) and a decreased bicarbonate (HCO3) level (<22 mEq/L). The ABG results show a pH of 7.30 and HCO3 of 18 mEq/L, which are consistent with metabolic acidosis. The low HCO3 indicates that there is an accumulation of acids or loss of bicarbonate in the blood.
B. Metabolic alkalosis is characterized by a high pH (>7.45) and an elevated bicarbonate level (>26 mEq/L). The ABG results show a low pH and low HCO3, which do not support metabolic alkalosis.
C. Respiratory alkalosis is characterized by a high pH (>7.45) and a low PaCO2 (<35 mm Hg). The pH in this scenario is low (7.30), which does not align with respiratory alkalosis.
D. Respiratory acidosis is characterized by a low pH (<7.35) and an elevated PaCO2 (>45 mm Hg). While the pH is low, indicating acidosis, the PaCO2 in this case is low (28 mm Hg), which does not support respiratory acidosis.
Correct Answer is A
Explanation
A. Troponin is a protein found in cardiac muscle cells. When there is damage to the heart muscle, such as during a myocardial infarction (heart attack), troponin is released into the bloodstream. Therefore, elevated troponin levels in the blood indicate myocardial injury or damage.
B. Troponin is not an enzyme; it is a protein. While there are enzymes such as creatine kinase (CK) and lactate dehydrogenase (LDH) that can indicate damage to various tissues including heart and skeletal muscles, troponin specifically indicates cardiac muscle damage.
C. Troponin is not involved in oxygen transport. Hemoglobin, found in red blood cells, is the protein responsible for oxygen transport in the body.
D. Troponin is not a lipid; it is a protein. Lipids include substances like cholesterol and triglycerides. Troponin levels do not reflect the risk for coronary artery disease; rather, they indicate acute damage to the heart muscle.
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