A client with thrombocytopenia is at risk of bleeding complications.
Which nursing intervention is essential to prevent and manage bleeding in this client?

Administering alternative anticoagulants.

Preparing the client for splenectomy.

Avoiding platelet transfusions.

Applying pressure to any bleeding site and elevating the affected area.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Administering alternative anticoagulants.

Administering alternative anticoagulants is not the primary intervention for preventing or managing bleeding in a client with thrombocytopenia.

Anticoagulants may increase the risk of bleeding in such patients and are generally not indicated unless there is a specific medical reason to use them.

Choice B rationale:

Preparing the client for splenectomy.

Splenectomy is not typically performed as a preventive measure for bleeding in thrombocytopenic patients.

While splenectomy may be considered in some cases of immune thrombocytopenia, it is not the essential nursing intervention to prevent or manage bleeding in most clients with thrombocytopenia.

Choice C rationale:

Avoiding platelet transfusions.

Avoiding platelet transfusions is not a recommended intervention in clients with thrombocytopenia who are at risk of bleeding complications.

Platelet transfusions are often necessary to raise platelet levels and prevent or manage bleeding in these individuals.

Choice D rationale:

Applying pressure to any bleeding site and elevating the affected area.

This is the essential nursing intervention to prevent and manage bleeding in clients with thrombocytopenia.

Applying pressure to a bleeding site helps control bleeding, and elevating the affected area can reduce swelling and minimize bleeding.

It is a fundamental measure in the care of thrombocytopenic clients.

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Correct Answer is B

Explanation

Choice A rationale:

"The platelet count is likely within the normal range." Rationale: This statement is unlikely to be true.

Given that the patient is presenting with mucosal bleeding, including petechiae, purpura, and gingival bleeding, it suggests a potential problem with platelet function.

Platelet counts within the normal range do not typically lead to these bleeding symptoms.

Choice B rationale:

"The platelet count may be below 50,000/uL, indicating a risk of prolonged bleeding." Rationale: This statement is accurate.

The symptoms described (petechiae, purpura, and gingival bleeding) are indicative of thrombocytopenia, where the platelet count is typically below 50,000/uL.

This lower count increases the risk of prolonged bleeding and bruising.

Choice C rationale:

"The platelet count is typically above 100,000/uL in thrombocytopenia." Rationale: This statement is not accurate.

Thrombocytopenia is characterized by a decrease in platelet count, often below 100,000/uL, as seen in choice B.

A platelet count above 100,000/uL is not typical in thrombocytopenia.

Choice D rationale:

"The platelet count does not affect bleeding symptoms." Rationale: This statement is incorrect.

Platelet count plays a significant role in the body's ability to form blood clots and prevent bleeding.

Low platelet counts can lead to bleeding symptoms, as described in the patient's presentation of mucosal bleeding.

Platelet count is indeed relevant in assessing and managing bleeding risk in thrombocytopenia.

A. Apply pressure to any bleeding site and elevate the affected area. B. Administer plasma exchange therapy. C. Monitor renal function and fluid balance. D. Prepare the client for immunosuppressant therapy.

Correct Answer is A

Explanation

Choice B rationale:

Administer plasma exchange therapy Administering plasma exchange therapy may be indicated in some cases of thrombocytopenia, but it is not the initial intervention when a client presents with petechiae, pallor, and weakness.

The primary concern in this situation is addressing active bleeding, which is best managed by applying pressure to bleeding sites and elevating the affected area.

Choice C rationale:

Monitor renal function and fluid balance While monitoring renal function and fluid balance is important in the overall care of a client with thrombocytopenia, it is not the immediate intervention when the client presents with symptoms of bleeding and weakness.

The priority is to stop the bleeding by applying pressure and elevating the affected area.

Choice D rationale:

Prepare the client for immunosuppressant therapy Immunosuppressant therapy may be considered as a treatment option for certain types of thrombocytopenia, but it is not the initial intervention when the client has active bleeding and weakness.

The immediate focus should be on bleeding control and symptom management.

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A client with thrombocytopenia is at risk of bleeding complications.Which nursing intervention is essential to prevent and manage bleeding in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with thrombocytopenia.The patient presents with mucosal bleeding, including petechiae, purpura, and gingival bleeding.What should the nurse anticipate when assessing this patient's platelet count?

Correct Answer is B

Explanation

A client with thrombocytopenia presents with petechiae, pallor, and weakness.Which intervention should the nurse implement to address the client's symptoms?

Correct Answer is A

Explanation

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