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. Encourage increased fluid take. B. Promote bed rest for 5-7 days. C. Place a pillow under the affected limb. D. Apply cool compresses to the affected limb every 6 hr.

Correct Answer is D

Explanation

A. Encouraging adequate fluid intake is important postoperatively to maintain hydration and support normal physiological functions. However, the amount of fluid intake should be within the client's tolerance and as prescribed by the healthcare provider. It helps prevent complications such as dehydration and promotes circulation, which is beneficial for wound healing.

B. While some rest and limited mobility are initially recommended after knee replacement surgery to allow for healing and to prevent complications, prolonged bed rest for 5-7 days is not typically necessary or recommended. Early mobilization and gradual increase in activity are encouraged to prevent complications such as deep vein thrombosis and to promote recovery.
C. Placing a pillow directly under the knee is not recommended as it can lead to decreased range of motion and potential contractures.
D. Cold therapy, such as applying cool compresses, is often used to reduce swelling and pain in the initial postoperative period. It can help manage pain and discomfort and promote comfort for the client.

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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 is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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