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.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: The medication administration record is an important document, but it is not the primary source for verification before administering blood products. It is used to record the administration after the fact.
Choice B reason: The identification wristband is the priority source for verification. It contains the client's essential information, such as name and hospital ID, which must match the blood product label to ensure patient safety⁸.
Choice C reason: The order sheet contains the physician's orders, which is crucial for verifying what has been prescribed but is secondary to the identification wristband for the actual administration process.
Choice D reason: The chart contains a comprehensive record of the client's medical history and care but is not the primary source for verification when administering blood products.
Correct Answer is D
Explanation
Choice A reason: Dependent rubor, a reddish coloration of the skin that occurs when the legs are in a dependent position, can be a sign of PAD, indicating poor arterial flow.
Choice B reason: Foot ulcers may occur in individuals with PAD due to poor blood circulation and the inability of sores or injuries to heal properly.
Choice C reason: Rest pain is a symptom of advanced PAD and occurs due to insufficient blood flow to the limbs even at rest, often worsening at night when the legs are elevated.
Choice D reason: Intermittent claudication, characterized by pain and cramping in the legs during exercise that disappears after rest, is a hallmark symptom of PAD and results from inadequate blood flow during increased activity.
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