A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority?
a. Calling the Rapid Response Team
b. Delegating taking a set of vital signs
c. Instituting bleeding precautions
d. Placing the client on bedrest
ANS: A
With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or putting the client back into bed is important, but the critical action is to call for immediate medical attention.
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