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

Apply pressure to any bleeding site and elevate the affected area.

Administer plasma exchange therapy.

Monitor renal function and fluid balance.

Prepare the client for immunosuppressant therapy.

Answer and Explanation

The Correct Answer is A

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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Correct Answer is B

Explanation

Choice A rationale:

Monitoring the patient's neurological status While monitoring neurological status is important in patient care, it is not the immediate priority when a patient with thrombocytopenia reports hematochezia (bloody stools), fatigue, and abdominal pain.

Checking vital signs helps assess the patient's overall stability and guides immediate interventions.

Choice C rationale:

Administering corticosteroids Administering corticosteroids may be a treatment option for certain types of thrombocytopenia, but it is not the initial priority in the assessment of a patient presenting with hematochezia, fatigue, and abdominal pain.

First, the nurse needs to assess the patient's condition and vital signs to determine the severity of the situation.

Choice D rationale:

Preparing the patient for a splenectomy Preparing a patient for a splenectomy is a significant intervention and should not be the initial priority in this case.

It may be considered as a treatment option in some cases of thrombocytopenia, but it should not take precedence over assessing the patient's vital signs and overall condition.

A. "A platelet count below 100,000/uL is considered normal.” B. "A platelet count below 50,000/uL can result in prolonged bleeding.” C. "Platelet count has no impact on bleeding risk.” D. "Bleeding risk increases with a platelet count above 150,000/uL.”

Correct Answer is B

Explanation

Choice A rationale:

"A platelet count below 100,000/uL is considered normal." Rationale: This statement is incorrect.

A normal platelet count typically ranges between 150,000 and 450,000/uL.

A platelet count below 100,000/uL is not considered normal and may indicate thrombocytopenia or another underlying issue.

Choice B rationale:

"A platelet count below 50,000/uL can result in prolonged bleeding." Rationale: This statement is correct.

Platelets are essential for normal blood clotting, and a platelet count below 50,000/uL can lead to an increased risk of bleeding, especially after minor trauma.

Severe bleeding risk typically occurs when the platelet count drops below 20,000/uL.

Choice C rationale:

"Platelet count has no impact on bleeding risk." Rationale: This statement is incorrect.

Platelet count directly affects bleeding risk.

A lower platelet count increases the risk of bleeding, while a higher count can lead to an increased risk of clot formation (thrombosis)

Choice D rationale:

"Bleeding risk increases with a platelet count above 150,000/uL." Rationale: This statement is incorrect.

A platelet count above 150,000/uL is within the normal range and does not increase the risk of bleeding.

Instead, it may increase the risk of thrombosis (excessive clotting)

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with thrombocytopenia.The patient reports experiencing hematochezia, fatigue, and abdominal pain.What should the nurse prioritize in the assessment of this patient?

Correct Answer is B

Explanation

A client with thrombocytopenia experiences prolonged bleeding even after minor trauma.What statement by the nurse accurately explains the relationship between platelet count and bleeding risk?

Correct Answer is B

Explanation

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