Question

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm��. Which of the following interventions should the nurse include in the plan of care?

a. Check the IV site for bleeding every 8hr
b. Limit IM injections
c. Obtain a rectal temperature every 8hr
d. Check the client for proteinuria

Answer 1

For a patient with leukemia and a platelet count of 130,000/mm³, the nurse should include interventions to prevent bleeding, such as limiting IM injections, and avoiding unsafe practices like obtaining rectal temperatures that could induce bleeding.

Step-by-step explanation:

The subject of this question is medicine, specifically concerning the care of a patient with leukemia and a low platelet count. When caring for a client with leukemia and a platelet count of 130,000/mm³, the nurse should include certain interventions to prevent bleeding complications. Such interventions include:

• Limiting intramuscular (IM) injections to avoid bleeding and bruising, due to the risk of further platelet depletion and poor clot formation.
• Monitoring the client for signs of bleeding, such as at intravenous (IV) sites, which should be checked for signs of bleeding more frequently than every 8 hours.
• Avoiding the measurement of rectal temperatures, which could cause trauma to the rectal mucosa and lead to bleeding.

Therefore, the most appropriate intervention to include in the plan of care would be to limit IM injections, as this helps in minimizing the risk of bleeding due to low platelet count.