Nokea
A client is undergoing chemotherapy and is at risk for developing thrombocytopenia. What precaution should the nurse teach the client to minimize the risk of bleeding?
- A. Use a soft-bristled toothbrush.
- B. Engage in daily aerobic exercise.
- C. Take aspirin for headaches.
- D. Use an electric razor for shaving.
Correct Answer: A
Rationale: The correct answer is A: Use a soft-bristled toothbrush. Chemotherapy can cause low platelet levels, increasing the risk of bleeding. Using a soft-bristled toothbrush can help prevent gum bleeding and trauma to the gums, reducing the risk of bleeding. Engaging in daily aerobic exercise (B) can increase the risk of injury and bleeding for a client with thrombocytopenia. Taking aspirin (C) can further decrease platelet function and increase bleeding risk. Using an electric razor (D) is recommended to prevent skin cuts and bleeding due to the fragile skin associated with chemotherapy-induced thrombocytopenia.
You may also like to solve these questions
A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Determine if the client received anesthesia during delivery.
- C. Assign a licensed nurse to reassess the client's vital signs.
- D. Obtain a STAT hemoglobin and hematocrit.
Correct Answer: B
Rationale: The correct answer is B because the client delivered a 7-pound infant 12 hours ago and is now experiencing a severe headache, which could indicate postpartum preeclampsia. Checking if the client received anesthesia during delivery is crucial as certain types of anesthesia can increase the risk of postpartum preeclampsia. This step is important to determine if anesthesia is a contributing factor to the client's symptoms.
Option A is incorrect because immediate action is needed to address the client's symptoms related to anesthesia. Option C is incorrect as reassessing vital signs alone may not provide information specific to the client's headache. Option D is incorrect as obtaining a hemoglobin and hematocrit would not directly address the client's headache or potential anesthesia-related issues.
What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm.
A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation.
B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation.
C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.
A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?
- A. Headache.
- B. Fever.
- C. Nuchal rigidity.
- D. Seizures.
Correct Answer: D
Rationale: The correct answer is D: Seizures. Seizures in a patient with suspected meningitis indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention to prevent brain damage or herniation. Headache (A), fever (B), and nuchal rigidity (C) are common symptoms of meningitis but do not pose an immediate threat to life like seizures do. Addressing the seizures first is crucial to prevent further complications and ensure the patient's safety.
A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?
- A. Refuses to eat her favorite meals at home.
- B. Drinks more soft drinks than previously.
- C. Voids only one or two times per day.
- D. Gained 10 pounds within one month.
Correct Answer: B
Rationale: The correct answer is B because increased thirst and drinking more fluids than usual is a common symptom of diabetes mellitus due to high blood sugar levels causing dehydration. Refusing to eat favorite meals (choice A) is not a typical symptom. Voids only one or two times per day (choice C) is more related to urinary issues than diabetes. Gaining 10 pounds within one month (choice D) is not a specific symptom of diabetes and can be attributed to various factors.
An elderly client with congestive heart failure (CHF) is admitted to the hospital. Which laboratory test result should the nurse expect to find?
- A. Elevated serum sodium level.
- B. Decreased brain natriuretic peptide (BNP) level.
- C. Increased serum creatinine level.
- D. Elevated hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: The correct answer is C, increased serum creatinine level. In CHF, the heart's reduced pumping ability can lead to decreased blood flow to the kidneys, resulting in impaired kidney function. This can cause an elevation in serum creatinine level, indicating decreased kidney function. Elevated serum sodium level (A) is not typically seen in CHF, as patients often have fluid retention leading to dilutional hyponatremia. Decreased BNP level (B) is not expected in CHF, as BNP is released in response to increased ventricular stretching and volume overload. Elevated hemoglobin and hematocrit levels (D) are not directly related to CHF; they may be seen in conditions like dehydration or chronic hypoxia, but not specifically in CHF.