A nurse is contributing to the plan of care for a client who has thrombocytopenia due to chemotherapy. Which of the following interventions should the nurse include?

Avoid IM injections.

Obtain a rectal temperature once per shift.

Do not allow the client to have visitors.

Encourage daily flossing between teeth.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct intervention, because avoiding IM injections can prevent bleeding and hematoma formation in the client who has low platelet count and impaired clotting.

Choice B reason: This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.

Choice C reason: This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.

Choice D reason: This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.

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Correct Answer is C

Explanation

Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.

Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.

Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.

Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.

A. Instruct the client to blink several times after instillation of the medication. B. Ask the client to look straight ahead during instillation of the medication. C. Apply pressure to the bridge of the nose after instillation of the medication. D. Place each drop of the medication directly on to the client's cornea.

Correct Answer is C

Explanation

Choice A reason: This is an incorrect action, because instructing the client to blink several times after instillation of the medication can cause the medication to drain out of the eye and reduce its effectiveness.

Choice B reason: This is a correct action, but not the best one. Asking the client to look straight ahead during instillation of the medication can help the nurse to aim the drop accurately and avoid touching the eye with the dropper.

Choice C reason: This is the best action, because applying pressure to the bridge of the nose after instillation of the medication can prevent the medication from entering the systemic circulation and causing adverse effects, such as bradycardia, hypotension, or bronchospasm.

Choice D reason: This is an incorrect action, because placing each drop of the medication directly on to the client's cornea can cause irritation, injury, or infection to the eye. The medication should be placed in the lower conjunctival sac of the eye.

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