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

a.While enemas may be part of bowel preparation, they are usually administered closer to the procedure, not 2 days in advance.

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

c.A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.

d.Removing polyps during a colonoscopy is a common procedure and does not necessarily require a separate procedure.

A. Have the client wear a surgical mask during transport. B. Wear an N95 mask while providing care to the client. C. Administer an influenza immunization to the client. D. Place the client in a negative airflow room.

Correct Answer is ["A"]

Explanation

a. Have the client wear a surgical mask during transport. This is the appropriate intervention to prevent the spread of the influenza virus when the client needs to be transported within the healthcare facility. Influenza is primarily spread through respiratory droplets, so wearing a surgical mask helps to contain these droplets.
b. Wear an N95 mask while providing care to the client. An N95 mask is generally not required for influenza. Standard precautions, including wearing a surgical mask when within close proximity to the client, are usually sufficient.
c. Administer an influenza immunization to the client. It is not appropriate to administer the influenza vaccine to a client who is already infected with the influenza virus.
d. Place the client in a negative airflow room. Negative airflow rooms are typically reserved for airborne diseases such as tuberculosis. Influenza, which spreads via droplets, does not require this level of isolation.

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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

Naxlex Comprehensive Predictor Exams

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

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A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

Correct Answer is ["A"]

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