A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.)

Blow nose gently.

Lubricate lips with water-soluble ointment.

Use a straightedge razor to shave.

Brush teeth with a soft toothbrush.

Limit fruit consumption.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Blowing the nose gently is advised to prevent nosebleeds, which can be a risk due to thrombocytopenia.

Choice B reason: Lubricating lips with water-soluble ointment can prevent cracking and bleeding, which is important for a patient with thrombocytopenia.

Choice C reason: Using a straightedge razor is not recommended because it can increase the risk of cuts and bleeding. An electric razor would be safer.

Choice D reason: Brushing teeth with a soft toothbrush is recommended to prevent gum bleeding due to the low platelet count associated with thrombocytopenia.

Choice E reason: Limiting fruit consumption is not necessary for thrombocytopenia unless the patient has a specific condition that requires dietary restrictions.

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Correct Answer is B

Explanation

Choice A reason: An oral temperature of 38.2°C (100.76°F) is slightly elevated but can be expected postoperatively as the body responds to surgical stress. It is not necessarily an indication of a complication unless it rises significantly or is accompanied by other symptoms.

Choice B reason: The output of burgundy colored urine can indicate bleeding in the urinary tract, which is a potential complication after TURP. Normal urine color ranges from pale yellow to deep amber, depending on hydration levels. Burgundy colored urine postTURP could suggest the presence of blood, warranting further assessment and intervention.

Choice C reason: Feeling an urge to void despite having an indwelling urinary catheter can be uncomfortable but is not uncommon after TURP due to irritation of the bladder. It is not typically a sign of a complication unless accompanied by other symptoms such as pain or difficulty urinating once the catheter is removed.

Choice D reason: A pulse rate of 58/min is within the normal resting range for adults, which is typically 60100 beats per minute. A lower than average pulse rate postoperatively might be normal for the patient, especially if they are on medications like betablockers, or it could be a sign of a good fitness level.

A. Diabetes mellitus B. Hyperlipidemia C. Gallstones D. Criminal record

Correct Answer is C

Explanation

Choice A reason: Diabetes mellitus is not directly associated with acute pancreatitis. However, longstanding diabetes can lead to chronic pancreatitis due to the damage it causes to the pancreas over time.

Choice B reason: Hyperlipidemia, specifically high levels of triglycerides in the blood, can be a risk factor for acute pancreatitis. Elevated triglyceride levels above 1000 mg/dL can precipitate an episode of acute pancreatitis.

Choice C reason: Gallstones are a common cause of acute pancreatitis. They can block the bile duct, leading to pancreatitis. It's estimated that gallstone disease is responsible for 3040% of acute pancreatitis cases.

Choice D reason: A criminal record is not a medical condition and has no relevance to the development of acute pancreatitis.

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A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.)

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