A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?

Have the client gently blow clots from his nose every 5 min

Instruct the client to sit with his head hyperextended

Apply ice compresses to the back of the client’s neck

Pinch the soft portion of the client’s nose for 10 min

Answer and Explanation

The Correct Answer is D

Choice A reason: Having the client gently blow clots from his nose every 5 min is an incorrect action, because it can increase the bleeding and trauma to the nasal mucosa. The client should avoid blowing or picking his nose.

Choice B reason: Instructing the client to sit with his head hyperextended is an incorrect action, because it can cause the blood to drain into the throat and increase the risk of aspiration or vomiting. The client should sit with his head tilted forward.

Choice C reason: Applying ice compresses to the back of the client’s neck is an incorrect action, because it has no effect on the bleeding site. The nurse should apply ice compresses to the bridge of the nose or the cheeks to constrict the blood vessels and reduce the bleeding.

Choice D reason: Pinching the soft portion of the client’s nose for 10 min is a correct action, because it applies direct pressure to the bleeding site and allows clot formation. The nurse should instruct the client to breathe through his mouth and avoid swallowing the blood.

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Correct Answer is D

Explanation

Choice A reason: This is an incorrect purpose, because raising the bed linens off the client's feet to prevent plantar flexion is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Raising the bed linens off the client's feet can be achieved by using a foot cradle or a bed frame.

Choice B reason: This is an incorrect purpose, because keeping the client's heels off the bed to prevent pressure ulcers is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Keeping the client's heels off the bed can be achieved by using a heel protector or a pillow under the lower legs.

Choice C reason: This is an incorrect purpose, because positioning the client off the operative site while in bed is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Positioning the client off the operative site can be achieved by using a trochanter roll or a pillow under the hip.

Choice D reason: This is the correct purpose, because preventing dislocation of the hip during position changes or movement is the main reason for using an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and

A. Place compression stockings on the lower extremities. B. Apply cold compresses to the affected extremity. C. Gently massage the area every 4 hr. D. Inform the client that heparin is prescribed to dissolve the thrombus.

Correct Answer is A

Explanation

Choice A reason: This is the best action, because compression stockings can help improve the blood flow and prevent the formation of new clots in the veins of the legs. Compression stockings can also reduce the swelling, pain, and inflammation caused by thrombophlebitis.

Choice B reason: This is an incorrect action, because cold compresses can cause vasoconstriction and worsen the blood flow and the clotting process in the affected vein. Cold compresses can also increase the discomfort and numbness of the extremity.

Choice C reason: This is an incorrect and dangerous action, because gently massaging the area can dislodge the clot and cause it to travel to the lungs, heart, or brain, resulting in a life-threatening complication, such as pulmonary embolism, myocardial infarction, or stroke.

Choice D reason: This is an incorrect and misleading statement, because heparin is not prescribed to dissolve the thrombus, but to prevent the growth and extension of the existing clot and the formation of new clots. Heparin is an anticoagulant that inhibits the clotting factors in the blood, but does not break down the clot. The body's own enzymes, such as plasmin, are responsible for dissolving the clot.

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A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?

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