The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
Hemoglobin levels.
Red blood cell count.
White blood cell count.
Platelet count.
The Correct Answer is D
A. Hemoglobin levels can indicate anemia but are not directly related to the presence of petechiae and ecchymosis, which suggest bleeding issues.
B. The red blood cell count is also important for understanding anemia but does not specifically address the bleeding disorders indicated by the client’s symptoms.
C. The white blood cell count provides information on the immune status but does not relate to bleeding manifestations.
D. The platelet count is critical to assess because petechiae and ecchymosis can be indicative of thrombocytopenia (low platelet count), which can lead to increased bleeding tendencies. Monitoring platelet levels will help determine the cause of these symptoms.
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Correct Answer is D
Explanation
A. Joint pain is a common symptom of systemic lupus erythematosus (SLE) and, while it may indicate an exacerbation of the disease, it is not the most critical finding to report.
B. A low-grade fever can signify an infection or increased disease activity but is generally not as urgent as changes in renal function or systemic involvement.
C. Muscle atrophy is a concern over time but does not pose an immediate threat to the client’s health compared to acute changes in kidney function.
D. Hematuria is significant in SLE as it can indicate renal involvement, such as lupus nephritis, which can lead to severe complications. This finding requires prompt reporting and assessment to prevent further renal damage and manage potential complications effectively.
Correct Answer is C
Explanation
A. Obtaining a sample of the drainage is not an immediate priority after evisceration; the patient's safety and stabilization come first.
B. Auscultating the abdomen for bowel sounds is important but secondary to addressing the immediate crisis of evisceration.
C. Preparing the client to return to the operating room is the priority action because evisceration indicates a surgical emergency that requires prompt intervention to repair the abdominal wall and prevent complications.
D. While additional sterile dressing supplies may be needed, addressing the evisceration takes precedence to prevent further injury and manage the patient’s condition.