A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

Wears a face mask around others

Sleeps 8 to 10 hr per night

Uses a firm bristled toothbrush

Increased intake of green, leafy vegetables

Answer and Explanation

The Correct Answer is C

A.   Incorrect. Wearing a face mask around others is not directly related to thrombocytopenia and does not impact the risk of injury in this context.
B.   Incorrect. Sleep duration is not directly related to thrombocytopenia and does not impact the risk of injury in this context.
C.   Correct. Using a firm-bristled toothbrush can increase the risk of bleeding in a client with thrombocytopenia due to potential gum injury. Soft-bristled toothbrushes are recommended to minimize the risk of injury and bleeding.
D.   Incorrect. Increased intake of green, leafy vegetables is generally beneficial for health and does not increase the risk of injury in thrombocytopenia.

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Correct Answer is B

Explanation

A. Incorrect. Dry mucous membranes are not typically associated with hyperkalemia.
B. Correct. Hyperkalemia can lead to cardiac dysrhythmias, including irregular heart rate.
C. Incorrect. Hyperactive reflexes are more commonly associated with hypokalemia (low potassium levels.
D. Incorrect. Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia.

A. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. B. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. C. A nurse discovers that a client's family member has administered a PCA dose. D. A nurse observes a client vomiting after receiving an oral pain medication.

Correct Answer is A

Explanation

A. Correct. This situation involves a potential medication error due to the electronic IV pump delivering excessive fluid, which requires documentation and an incident report for reporting and tracking purposes.
B. While observing another nurse's practice is important, the scenario does not involve an incident that requires reporting via an incident report.
C. This situation may warrant a medication incident report, but the family member's administration of PCA might be within their scope if properly trained and authorized.
D. This scenario involves a side effect of a medication, but it is not a situation requiring an incident report unless it is a severe or unexpected reaction.

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A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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