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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the correct answer because BUN and creatinine are the most important laboratory values to monitor for nephrotoxicity, which is the damage or injury to the kidneys caused by certain drugs or chemicals.
Nephrotoxicity can impair the kidneys' ability to filter waste products from the blood, resulting in elevated levels of BUN and creatinine. The normal range for BUN is 7 to 20 mg/dL, and for creatinine is 0.6 to 1.2 mg/dL. The practical nurse (PN) should review these values before administering an antibiotic that can cause nephrotoxicity, such as aminoglycosides, cephalosporins, vancomycin, or sulfonamides. The PN should also monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, fatigue, nausea, and confusion.
Correct Answer is D
Explanation
Verifying the completion of all new prescriptions is crucial because it ensures that necessary medications or treatments are not delayed or missed for the clients. By reviewing the new prescriptions, the PN can ensure that any necessary medications or treatments are ordered and completed as required. This task takes priority because it directly impacts the immediate care and well-being of the clients.
While the other tasks mentioned are also important, they are not as time-sensitive or critical as verifying the completion of new prescriptions:
A. "Clean up and organize the nurses' work-station": While maintaining a clean and organized work-station is important for efficiency and safety, it can be done after the more critical tasks have been completed.
B. "Write a narrative shift summary for each client": Providing shift summaries is important for effective communication and continuity of care, but it can be done after ensuring the completion of new prescriptions, as it involves documenting and reviewing the events and assessments that occurred during the shift.
C. "Calculate and record intake and output totals": Tracking intake and output is important for assessing fluid balance, but it can also be done after verifying the completion of new prescriptions, as it involves documenting and calculating fluid volumes.
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