NursGuru

    Bsn 366 RN Hesi Exit (nightingale) Proctored Exam

    Tutor Mode

    0m 00s
    Question: 1 of 125Bsn 366 Rn Hesi Exit (Nightingale) Proctored Exam
    A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet count [150,000 to 400,000/mm3 (150 to 400 x 109/L)]
    Explanation
    A. Monitoring for activity intolerance is important in clients with anemia, which is common in leukemia and chemotherapy due to decreased red blood cells. However, a platelet count of 25,000/mm³ indicates severe thrombocytopenia, placing the client at high risk for bleeding rather than fatigue-related complications. Therefore, while this assessment may be relevant, it is not the priority intervention for this platelet level. B. Requiring visitors to wear respiratory masks is an infection control measure appropriate for clients with neutropenia (low white blood cell count). Although myelosuppressive chemotherapy can also reduce white blood cells, the question specifically highlights a critically low platelet count. Thus, bleeding—not infection—is the immediate concern, making this option less relevant to the current priority. C. This is the most important intervention. A platelet count of 25,000/mm³ significantly increases the risk of spontaneous bleeding, including internal bleeding that may not be immediately visible. Assessing urine and stool for occult blood allows for early detection of hidden (internal) bleeding in the gastrointestinal or urinary tract. Early identification enables prompt intervention, such as platelet transfusions or activity restrictions, to prevent life-threatening hemorrhage. Monitoring for bleeding is a priority in severe thrombocytopenia. D. Monitoring temperature every 4 hours is appropriate for detecting infection, especially in immunocompromised clients. However, this intervention is more directly related to neutropenia rather than thrombocytopenia. While still important in the overall care of a client receiving chemotherapy, it is not the priority given the immediate risk of bleeding associated with the critically low platelet count.
    Submit to Reveal Answer