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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is E, D, C, A, B

Explanation

Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.

Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.

Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.

Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.

Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.

A. Administer enemas 2 days before the procedure B. Do not eat or drink anything except water for 12 hr. before the procedure. C. Restrict the diet to clear liquids for 1 to 3 days before the procedure. D. Expect the provider to schedule another procedure to remove any polyps

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is E, D, C, A, B

Explanation

A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

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?

A nurse is reinforcing teaching with a client who has a prescription for sublingual nitroglycerin for unstable angina. Which of the following instructions should the nurse include in the instructions?

A nurse administered a dose of penicillin to a client 30 min ago. The client reports she has hives and is itching. Which of the following statements by the nurse is the highest priority?

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?

A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?