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.
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Related Questions
Correct Answer is B
Explanation
The practical nurse (PN) plays a crucial role in obtaining consent for an invasive examination. The PN should explain the examination to the client, ensuring that the client has a clear understanding of the procedure, its purpose, and any associated risks or benefits. After providing this information, the PN can ask the client to sign the consent form voluntarily, indicating their agreement to undergo the examination.
A. Checking the medical record for the correct signed consent form prior to the examination is a responsibility that typically falls on the healthcare provider who will be performing the procedure, such as a physician or advanced practice nurse. The PN may assist in verifying the presence of a signed consent form, but their primary responsibility lies in explaining the examination to the client and obtaining their consent.
C. While involving family members in the consent process can be important for communication and support, the consent form should be signed by the individual who will undergo the examination. Obtaining the signature of a family member alone is not sufficient for informed consent.
D. Asking if the client understands the exam and the reason for signing the consent form is a crucial step in the consent process. The PN should ensure that the client has a clear understanding and address any questions or concerns they may have before proceeding with obtaining the consent form.
Correct Answer is ["500ml"]
Explanation
1 liter is equal to 1000 milliliters. Therefore, to calculate the fluid intake in mL, we can multiply 1/2 liter by 1000 mL/liter:
1/2 liter * 1000 mL/liter = 500 mL
So, the practical nurse should document 500 mL as the client's fluid intake.
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