A nurse is caring for a patient diagnosed with thrombocytopenia. Which of the following interventions should the nurse prioritize to ensure the safety of the patient?
Encourage the patient to engage in strenuous exercise to improve circulation
Instruct the patient to use an electric razor for shaving
Teach the patient to use a water pick for oral hygiene
Request an order for subcutaneous heparin to prevent blood clots
The Correct Answer is B
Choice A reason: Encouraging the patient to engage in strenuous exercise to improve circulation is not appropriate for someone with thrombocytopenia. Strenuous exercise can increase the risk of injury and bleeding, which is particularly dangerous for patients with a low platelet count.
Choice B reason: Instructing the patient to use an electric razor for shaving is the most appropriate intervention. Thrombocytopenia increases the risk of bleeding, and using an electric razor instead of a traditional blade helps minimize the risk of cuts and subsequent bleeding.
Choice C reason: Teaching the patient to use a water pick for oral hygiene is not recommended for thrombocytopenia patients. Water picks can cause bleeding of the gums, which is a concern for individuals with low platelet counts. Using a soft-bristled toothbrush is safer.
Choice D reason: Requesting an order for subcutaneous heparin to prevent blood clots is not advisable for a thrombocytopenia patient without specific medical indication. Heparin is an anticoagulant, and administering it to someone with low platelets can exacerbate the risk of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Respiratory status is crucial to monitor because patients with acute neurological deficits, such as those seen in strokes, are at risk of respiratory compromise. This can be due to weakened respiratory muscles or aspiration, which could lead to pneumonia or other respiratory complications.
Choice B reason: Monitoring liver enzymes is not directly related to the acute management of a stroke patient. Liver enzymes would be more relevant in cases where liver function or hepatic issues are suspected, but not for this specific scenario.
Choice C reason: Blood pressure monitoring is vital, as hypertension is a significant risk factor for stroke. Maintaining appropriate blood pressure is essential to prevent further neurological damage and complications. Acute changes in blood pressure can indicate worsening or improvement of the patient's condition.
Choice D reason: Neurological status should be continuously monitored to assess the progression of the patient's stroke symptoms. This includes checking for changes in level of consciousness, motor function, speech, and other neurological signs. Prompt detection of changes can guide immediate interventions.
Choice E reason: Potassium level monitoring is not a primary focus in the acute management of stroke. While electrolyte balance is important, it is not as critical as respiratory status, blood pressure, and neurological status in this context.
Correct Answer is D
Explanation
Choice A reason: The nurse assistant typically performs tasks such as patient hygiene, ambulation, and basic monitoring under the supervision of registered nurses. They are not usually responsible for documenting vital signs during the intra-operative period.
Choice B reason: The anesthesiologist is primarily focused on managing the patient's anesthesia and monitoring their physiological status during surgery. While they do keep track of vital signs, the formal documentation is typically the responsibility of the circulating nurse.
Choice C reason: The scrub nurse is focused on maintaining the sterile field, handling surgical instruments, and assisting the surgeon. They do not leave the sterile field to document vital signs.
Choice D reason: The circulating nurse is responsible for overall patient care in the operating room, including documentation of vital signs. They manage the operating room environment, ensure patient safety, and record all necessary information during the intra-operative period.
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