HESI RN Medical Surgical Proctored Exam
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 data which reveals a platelet count of 25,000/mm3 (25 X109/L), which intervention should the nurse include in the plan of care?Reference Range Platelets [150,000 to 400,000/mm" (150 to 400 x 109/L)]
Explanation & Rationale
A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient. B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding. C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts. D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.
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