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. Instructing the client's family about the purpose of mitten restraints requires nursing judgment and explanation. It is beyond the scope of an assistive personnel's role.
B. Correct. Assisting the client with a range of motion exercises of the hands is a task that can be safely delegated to assistive personnel. It is a routine activity and does not require advanced assessment.
C. Incorrect. Evaluating the need for the client to remain in restraints requires nursing assessment and decision-making.
D. Incorrect. Determining the circulation status of the extremities requires nursing assessment skills and clinical judgment. It is not appropriate to delegate this task to assistive personnel.

A. Elevate the arm. B. Document the infiltration. C. Stop the infusion. D. Apply a warm compress.

Correct Answer is C

Explanation

A. Incorrect. Elevating the arm might help reduce edema, but the priority is to stop the infusion to prevent further infiltration.
B. Incorrect. While documenting the infiltration is important, immediate action should be taken to stop the infusion to prevent further complications.
C. Correct. The nurse's first action should be to stop the infusion to prevent the continuation of fluid infiltration and potential complications.
D. Incorrect. Applying a warm compress might help with comfort, but stopping the infusion is the priority to prevent further infiltration.

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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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Correct Answer is B

Explanation

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Explanation

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