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 A

Explanation

The correct answer is choicea. Obtain the client’s blood pressure in the other arm.

Choice A rationale:

Obtaining the client’s blood pressure in the other arm is crucial to avoid compromising the arteriovenous fistula. Measuring blood pressure in the arm with the fistula can damage the access site and impair its function.

Choice B rationale:

Encouraging the client to increase fluid intake is not appropriate for clients undergoing hemodialysis, as they often need to restrict fluid intake to prevent fluid overload.

Choice C rationale:

Reinforcing with the client to sleep on the side of the access site is incorrect. Clients should avoid sleeping on the arm with the fistula to prevent compression and potential damage to the access site.

Choice D rationale:

Obtaining the client’s weight is important for monitoring fluid balance, but it is not specific to the care of the arteriovenous fistula.

A. Reduced fat in the stools B. Improved absorption of vitamins B and C C. Improved respiratory function D. Decreased sodium excretion

Correct Answer is A

Explanation

A. Correct. Pancre-lipase is an enzyme replacement therapy used in cystic fibrosis to improve digestion and absorption of fats. Reduction in fat in the stools indicates improved fat digestion.
B. Improved absorption of vitamins B and C might occur as a result of improved overall digestion, but it is not the primary therapeutic effect of pancre-lipase.
C. Improved respiratory function is not a direct effect of pancre-lipase.
D. Decreased sodium excretion is not a primary therapeutic effect of pancre-lipase.

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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 A

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Correct Answer is A

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