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

Wears a face mask around others

Increased intake of green, leafy vegetables

Uses a firm-bristled toothbrush

Sleeps 8 to 10 hr per night

Answer and Explanation

The Correct Answer is C

A. Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.

B. Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.

C. Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.

D. Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.

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Correct Answer is A

Explanation

Explanation

A. Administer the medication to the toddler each evening.

Montelukast is a long-term control medication used for the management of asthma in both children and adults. It is typically taken once daily in the evening to provide continuous asthma control. Consistency in taking the medication is important to maintain its effectiveness.

Providing an additional dose of the medication prior to physical activity in (option B) is not a standard recommendation for montelukast use. Montelukast is not a rescue medication and does not provide immediate relief for asthma symptoms triggered by physical activity. In such cases, a short-acting bronchodilator medication, such as albuterol, is commonly used prior to physical activity.

Mixing the medication in juice prior to administration in (option C) is not recommended unless specifically instructed by the healthcare provider or indicated in the medication instructions.

Montelukast is available in various formulations, including chewable tablets and granules, which can be taken directly or mixed with certain foods or liquids. However, the specific instructions should be followed as provided by the healthcare provider or medication label.

Administering the medication when the toddler in (option D) has an acute asthma attack is not the intended use of montelukast. Montelukast is a long-term control medication aimed at preventing asthma symptoms and maintaining asthma control over time. For acute asthma attacks, a short-acting bronchodilator medication is typically used.

Therefore, the nurse should instruct the parents to administer the medication to the toddler each evening (option A) as part of the routine, long-term management of asthma.

A. We will keep the client's fluid intake restricted until he is free of pain. B. Expect the stoma to appear pale until healing is complete. C. We need to check the client's urine output every hour. D. Expect the diet’s urine to contain clots for the first 24 hours.

Correct Answer is C

Explanation

Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.

Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.

Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.

Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.

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A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that 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

Explanation

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Correct Answer is C

Explanation

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