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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The blood should not be infusing for 5 hours as transfusions of packed RBCs should be completed within 2 to 4 hours to minimize the risk of bacterial growth and transfusion reactions.
Choice B reason: Medications should not be administered through the same IV line as blood products due to the risk of reactions and interactions.
Choice C reason: The packed RBCs are indeed connected by Tubing to normal saline, which is used to keep the line open and prevent clotting.
Choice D reason: The drip chamber should not be filled completely with blood as it is necessary to monitor the drip rate and to ensure that air does not enter the line.
Correct Answer is B
Explanation
Choice A reason: Respiratory Alkalosis Partially Compensated is characterized by an elevated pH over 7.45 and a PaCO2 under 35 mmHg, with a compensatory acidic HCO3 under 22 mEq/L. This does not match the patient's ABG results.
Choice B reason: Respiratory Acidosis Uncompensated is indicated by an acidic pH under 7.35 and an elevated PaCO2 over 45 mmHg, with HCO3 in the normal range of 2226 mEq/L. The patient's ABG results show a low pH and high PaCO2, which aligns with this condition.
Choice C reason: Metabolic Alkalosis Partially Compensated would show a basic pH over 7.45 and a basic HCO3 over 26 mEq/L, with a compensatory acidic PaCO2 over 45 mmHg[^10^]. The patient's ABG values do not support this diagnosis.
Choice D reason: Metabolic Acidosis Uncompensated would present with an acidic pH under 7.35 and an acidic HCO3 under 22 mEq/L, with PaCO2 in the normal range of 3545 mmHg⁸. The patient's normal HCO3 level does not indicate metabolic acidosis.
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