A nurse is caring for a patient who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoseson the patient's sacral area and petechiae in her forearms
In addition to informing the patient's primary care provider, the nurse should perform what action?
A) Initiate measures to prevent venous thromboembolism (VTE).
B) Check the patient's most recent platelet level.
C) Place the patient on protective isolation.
D) Ambulate the patient to promote circulatory function.
Ans: B
Feedback:
The patient's signs are suggestive of thrombocytopenia, thus the nurse should check the patient's most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.
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