A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for:

Fatigue

Side effects of immunosuppressants

Thrombocytopenia

Infection

Answer and Explanation

The Correct Answer is C

Choice A reason: Fatigue is a common symptom of ITP but is not the primary concern for monitoring, as it does not directly indicate the severity of the condition.

Choice B reason: While monitoring for side effects of immunosuppressants is important, it is not the priority concern. The primary issue in ITP is the low platelet count, which poses a risk of bleeding.

Choice C reason: Thrombocytopenia, or low platelet count, is the hallmark of ITP and the main concern for monitoring, as it increases the risk of bleeding and bruising.

Choice D reason: Infection is a risk due to the potential use of immunosuppressants in treatment; however, the immediate concern in ITP management is the platelet count and associated bleeding risk.

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Correct Answer is D

Explanation

Choice A reason: The prone position is not suitable for abdominal paracentesis as it does not allow access to the abdominal cavity.

Choice B reason: The lateral position is also not suitable as it can cause the fluid to shift, making it difficult to remove.

Choice C reason: While the supine position is commonly used for many medical procedures, it is not the best choice for abdominal paracentesis due to the distribution of fluid.

Choice D reason: The upright position is preferred because it allows the fluid to pool at the lowest point of the abdominal cavity, facilitating its removal.

A. Serum creatinine 1.8 mg/dL B. Magnesium 2.0 mEq/L C. Blood urea nitrogen (BUN) 20 mg/dL D. Serum osmolality 290 mOsm/kg H2O

Correct Answer is A

Explanation

Choice A reason: Serum creatinine is a waste product from the normal breakdown of muscle tissue. A level of 1.8 mg/dL is higher than the normal range (0.61.2 mg/dL for females), indicating impaired kidney function and an increased risk of AKI.

Choice B reason: A magnesium level of 2.0 mEq/L is within the normal range (1.72.2 mEq/L) and does not typically indicate an increased risk of AKI.

Choice C reason: A BUN level of 20 mg/dL is within the normal range (720 mg/dL) and does not suggest an increased risk of AKI by itself.

Choice D reason: A serum osmolality of 290 mOsm/kg H2O is within the normal range (275295 mOsm/kg H2O) and does not indicate an increased risk of AKI.

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A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for:

Nursing Test Bank

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Correct Answer is D

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