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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gather the procedure tray and equipment – The practical nurse should gather all necessary supplies for the healthcare provider to perform the thoracentesis efficiently. Preparing the equipment beforehand ensures that the procedure can start promptly and reduces interruptions for missing supplies.
Rationale for Incorrect Answers:
B. Cleanse the site and cover with a sterile towel – This action should be performed by the healthcare provider immediately before the procedure to maintain sterility. The PN’s role is to prepare equipment and ensure the client is positioned correctly.
C. Keep the patient NPO (nothing by mouth) and encourage them to void – While voiding may be encouraged before some procedures to improve client comfort, it is not necessary for thoracentesis. Additionally, keeping the client NPO is not required, as the procedure does not typically involve sedation that would necessitate this restriction.
D. Place the patient in an orthopneic position – This may be done just before the procedure, but the healthcare provider typically directs the final positioning. Initial positioning or seating at the bedside can be done, but orthopneic positioning should follow the provider’s instructions.
Correct Answer is A
Explanation
This is the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Health care proxy documentation is a legal document that appoints a person to make health care decisions for the client when they are unable to do so themselves. It is important to have this information in case the client's condition deteriorates and they need end-of-life care.
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