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. Oxycodone is an opioid analgesic used for moderate to severe pain management but is not typically the first-line medication in acute coronary syndrome scenarios.
B. Fentanyl is a potent opioid that may be used for severe pain; however, morphine is more commonly used in emergency situations for chest pain related to potential myocardial infarction.
C. Morphine is commonly used in emergency departments for the management of acute chest pain, particularly when associated with myocardial ischemia. It helps reduce pain and anxiety, lowers myocardial oxygen demand, and has vasodilatory effects that can alleviate the burden on the heart.
D. Hydromorphone is another opioid analgesic but is not usually the preferred choice for chest pain in the acute setting compared to morphine.
Correct Answer is A
Explanation
A. Tenderness upon palpation and generalized erythema indicate skin irritation and possible sunburn, which are signs of overexposure to PUVA treatment. This finding suggests that the client may have received excessive ultraviolet exposure, leading to skin damage.
B. Thick skin plaques topped by silvery white scales are characteristic of psoriasis vulgaris itself, not a sign of overexposure to PUVA.
C. Requiring sunglasses because sunlight hurts the eyes may indicate sensitivity but is not a specific indicator of overexposure to PUVA treatment; it could relate to other issues such as underlying eye conditions.
D. Brown, rough, greasy, wart-like papules on the face are not typically associated with PUVA overexposure but could be related to other skin conditions or lesions.