A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?
Monitor urine and stool for occult blood regularly.
Ensure a large gauge catheter is used to obtain blood samples.
Remove cold and frozen foods from dietary trays.
Wrap bruised areas with elastic bandage dressings.
The Correct Answer is A
A. Monitoring for occult blood in urine and stool is crucial in clients with low platelet counts to detect any potential bleeding early, as they are at increased risk of bleeding due to thrombocytopenia.
B. Using a large gauge catheter may be necessary for some procedures, but it is not the priority intervention regarding the client’s current state and platelet count.
C. Removing cold and frozen foods from dietary trays does not directly address the critical concern of bleeding associated with low platelet levels.
D. While protecting bruised areas is important, it is secondary to monitoring for active bleeding, which is more critical at this stage.
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Correct Answer is C
Explanation
A. While monitoring blood glucose levels is important for managing diabetes, this instruction alone does not specifically address the goal of lowering blood glucose levels and increasing HDL levels.
B. Monthly appointments with a dietitian can be beneficial but are not as essential as incorporating regular exercise into the client’s lifestyle.
C. Regular exercise is a key component in managing type 2 diabetes, as it helps to lower blood glucose levels and can improve HDL cholesterol. Medical approval ensures that the exercise regimen is safe for the client.
D. Limiting calories on days unable to exercise is not a primary focus for managing diabetes and may not be practical or effective in promoting overall health.
Correct Answer is C
Explanation
A. Clear, dark amber-colored urine may indicate dehydration or concentrated urine, which does not necessarily signify improvement in liver function or treatment efficacy.
B. A prothrombin time within normal limits may indicate improved liver function; however, it is not the primary goal of the treatment plan focused on managing ascites and fluid retention in cirrhosis.
C. Decreased abdominal girth is a key indicator of progress in managing fluid retention associated with cirrhosis, as the treatment plan aims to reduce ascites through a low sodium diet and albumin infusions.
D. Improved level of consciousness is essential for overall recovery but is not the primary measure of progress related to fluid management and treatment effects in this context.