A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Assess the client for nerve pain or paralysis.

Ensure the client has minimal clutter in the room.

Evaluate the client's neurological status after exercising.

Monitor the client's blood cell laboratory values.

Answer and Explanation

The Correct Answer is B

To prevent injury in a female client with immune thrombocytopenic purpura (ITP) who is transferred to a long-term care facility for physical rehabilitation, the most important action for the practical nurse to implement is to ensure the client has minimal clutter in the room.

ITP is a condition characterized by a low platelet count, which can result in an increased risk of bleeding and bruising. Clutter in the room can pose a hazard and increase the risk of injury. The client may accidentally bump into objects or trip over items, potentially leading to falls or injuries.

Incorrect:

A- Assessing the client for nerve pain or paralysis is important but may not be directly related to preventing injury in this context. It is essential to address these concerns but not the most important action in preventing injury.

C- Evaluating the client's neurological status after exercising is important for overall assessment and monitoring but does not specifically address the prevention of injury.

D- Monitoring the client's blood cell laboratory values is essential for managing the client's condition but does not directly address preventing injury. It focuses more on the medical management of the client's ITP.

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Correct Answer is B

Explanation

The patient experienced a sudden guard while being assisted to the bathroom, which led to their hospitalization. The most appropriate action for the practical nurse (PN) in this situation is to prioritize the patient's safety and well-being. Returning the patient to bed and maintaining bed rest allows for stability and minimizes the risk of further complications or injury. By providing a safe and controlled environment, the PN can monitor the patient's condition and collaborate with the healthcare team to determine the appropriate course of action moving forward.

Options a), c), and d) are not relevant or appropriate in this context.

A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" C. "Part of recovery is accepting your new body image, and you will need to look at your incision." D. "You will feel better when you see that the incision is not as bad as you may think."

Correct Answer is A

Explanation

When a client refuses to look at their mastectomy incision and refuses to talk about it, the best response by the practical nurse (PN) is to respect the client's autonomy and validate their feelings. Option a) acknowledges the client's discomfort and provides reassurance that it is okay for them to decline to look or talk about the incision at the moment. It also oﬀers support by letting the client know that the incision will be available for examination when they feel ready to do so.

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A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is being assisted to the bathroom for the first time after Caeserean delivery. A recent experience caused a sudden fall made the client end up at the hospital. The options for the practical nurse (PN) are:

Correct Answer is B

Explanation

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

Correct Answer is A

Explanation

A client who had a knee replacement surgery and received a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL pre-filled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.)

During a routine prenatal visit at the antepartal clinic, a multipara at 35 weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the practical nurse (PN) report to the registered nurse?

The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client's plan of care?

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

The practical nurse (PN) hears an older resident of a long-term care facility shout profanities at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take?