A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

Check the client for ecchymosis.

Initiate protective isolation for the client.

Administer ibuprofen for mild headache.

Instruct the client to shave with a disposable razor.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Checking the client for ecchymosis is appropriate. Thrombocytopenia increases the risk of bleeding and bruising, so monitoring for ecchymosis (bruising) is essential to detect any signs of bleeding. Ecchymosis can occur more easily in individuals with low platelet counts.
Choice B Reason:
Initiating protective isolation for the client is typically unnecessary solely due to thrombocytopenia. Protective isolation is generally for clients with conditions that compromise their immune system or make them more susceptible to infections.
Choice C Reason:
Administering ibuprofen for a mild headache might not be advisable in someone with thrombocytopenia because ibuprofen can affect platelet function and potentially increase the risk of bleeding.
Choice D Reason:
Instructing the client to shave with a disposable razor isn't recommended because using a sharp blade can increase the risk of cuts and bleeding in someone with a low platelet count. Using an electric razor or avoiding shaving might be safer options to prevent injury and bleeding.

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Correct Answer is B

Explanation

Choice A Reason:

Administering enemas 2 days before the procedure. Enemas are not typically the primary method of bowel preparation for a colonoscopy. Healthcare providers often recommend specific bowel preparation solutions or laxatives that are more effective in thoroughly cleansing the colon.

Choice B Reason:

This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.

Choice C Reason:

This is not necessary for a colonoscopy. A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.

Choice D Reason:

Expect the provider to schedule another procedure to remove any polyps. While identifying and removing polyps is part of the objective of a colonoscopy, scheduling another procedure specifically for polyp removal isn't usually discussed beforehand. Polyp removal is often performed during the colonoscopy procedure if any are found.

A. will use a skin sealant before I apply the bag." B. will use moisturizing soap to clean around the stoma before applying the bag." C. will cut the wafer opening one-fourth of an inch larger than the stoma D. 1 will need to empty the bag every 4 to 6 hours."

Correct Answer is A

Explanation

Choice A Reason:

"I will use a skin sealant before I apply the bag." This statement is appropriate. Using a skin sealant before applying the ostomy bag helps protect the skin around the stoma, creating a barrier against irritation and potential leaks from the stool. It demonstrates the client's understanding of preventive measures to maintain skin integrity.

Choice B Reason:

"I will use moisturizing soap to clean around the stoma before applying the bag." This statement is inappropriate. While keeping the area around the stoma clean is important, using moisturizing soap might not be recommended as it can leave residue and interfere with the adhesive properties of the bag. Typically, mild soap and water are recommended for cleansing.

Choice C Reason:

"I will cut the wafer opening one-fourth of an inch larger than the stoma." This statement is incorrect. Cutting the wafer opening one-fourth of an inch larger than the stoma might result in an excessively large opening, potentially leading to leaks or irritation. The ideal size is generally recommended to be as close to the stoma size as possible without causing pressure on the stoma.

Choice D Reason:

"I will need to empty the bag every 4 to 6 hours." This statement is incorrect. While regular emptying of the ostomy bag is necessary, the frequency can vary based on individual needs and stoma output. Some individuals might need to empty it more frequently or less often, depending on their stool output and comfort level.

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A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

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