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 skin turgor
B. Assess bowel sounds
C. Assess temperature
D. Assess level of consciousness
Correct Answer: D. Assess level of consciousness
Option D: 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 A: Skin turgor will be assessed if there is a presence of dehydration in a patient with low platelet count but it is not the priority.
Option B: Bowel sounds will be assessed when there is a presence of gastrointestinal complications such as constipation, diarrhea, and radiation enteritis.
Option C: Assessing the temperature is a priority nursing assessment when the white blood cell count is low and the client is at risk for an infection.
No comments:
Post a Comment