The nurse is reviewing the laboratory results of a client receiving chemotherapy. The platelet count is 10,000 cells/mm. Based on this laboratory value, the priority nursing assessment is which of the following?
A. Assess level of consciousness
B. Assess temperature
C. Assess bowel sounds
D. Assess skin turgor
Answer: A
Explanation: A high risk of hemorrhage exists when the platelet count is fewer than 20,000. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is fewer than 10,000. The client should be assessed for changes in levels of consciousness, which may be an early indication of an intracranial hemorrhage. Option 2 is a priority nursing assessment when the white blood cell count is low and the client is at risk for an infection.
You might also like to view...
The nurse manager is determining the unit budget for the next fiscal year. The current year's expenses for the care area are $1,425,740
If the percentage increase for the next year is to be 5% what should the manager calculate as being the next year's budget? (Calculate to the nearest whole number.)
A nurse records a "1" for the pulse quality of the pedal pulse. What interpretation is correct regarding the pulse?
a. Absent b. Normal c. Thready d. Forceful
A client has the nursing diagnosis Fear related to the unknown regarding upcoming surgery. The nurse would know that goals for this diagnosis have been met when the client says "I feel a little better now because
a. a nurse will be with me during the entire experience." b. I can tolerate anything for 2-3 hours." c. I know I won't have any complications." d. this operation is really routine and done all the time."
The nurse is caring for a patient diagnosed with an abdominal aortic aneurysm who complains of sudden, intense abdominal pain and light-headedness. What action should the nurse take next?
a. Monitor the patient's blood pressure every 15 minutes. b. Contact the physician immediately. c. Notify the patient's family of the change in condition. d. Continue to assess the patient's pain.