Question

During the admission assessment, the nurse identifies multiple bruises at various stages of heating on a client recently diagnosed with aplastic anemia. The nurse reviews the client's stat serum laboratory values which reveal platelets 50,000/mm° (5 x 10°L), white blood cells 3,000/mm° (3 % 10°/L.), and red bloods cells 2.5 million/mm? (2.5 x 10*°). Which actions should the nurse Implement? (Select all that apply.)

a. Implement contact precautions.
b. Monitor for signs of bleeding.
c. Provide a soft-bristle tooth brush.
d. Initiate sepsis protocol
Infuse blood products as prescribed.

Answer 1

The nurse should monitor for signs of bleeding, provide a soft-bristle toothbrush, and infuse blood products as prescribed for a client with aplastic anemia.

Step-by-step explanation:

Based on the given information, the nurse should implement the following actions:

• Monitor for signs of bleeding: Bruises at various stages of healing indicate a risk of bleeding. The nurse should closely observe the client for any signs of active bleeding such as bleeding gums or nosebleeds.
• Provide a soft-bristle toothbrush: A client with low platelet count is at risk of bleeding gums. Using a soft-bristle toothbrush can help prevent gum bleeding.
• Infuse blood products as prescribed: Since the client has low platelet count and red blood cell count, the nurse may need to administer blood products such as platelets and packed red blood cells to improve their blood values.