A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

Elevated WBC

Fever

Fatigue

Ecchymosis

Answer and Explanation

The Correct Answer is D

A. Elevated WBC is not typically associated with ITP, which primarily affects platelet counts.
B. Fever may indicate infection but is not specific to ITP.
C. Fatigue can occur in clients with ITP due to anemia or chronic illness but is not specific to the condition.
D. Ecchymosis (bruising) is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies.

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Correct Answer is D

Explanation

A. Allowing free movement could increase the risk of falls due to dizziness.
B. While involving the provider is important, immediate safety measures should be communicated directly.
C. Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.

A. Are you fully insured? B. Is it possible that you are pregnant? C. Do you take any medications? D. What was your last meal? E. What happened before you fell? F. Do you live with anyone?

Correct Answer is ["A","B","D","F"]

Explanation

A. Peripheral IV in large vein
Vancomycin should be administered through a large-bore IV to minimize the risk of complications such as phlebitis and to ensure effective drug delivery. This is a key factor in safely administering the medication.
B. Dosage in safe range
Confirming that the dosage is within the safe range ensures that the medication is administered at an effective but non-toxic level. Proper dosing is essential for achieving therapeutic effects without causing harm.
C. No known allergies
Ensuring that the client has no known allergies to vancomycin is critical to prevent allergic reactions. This step is necessary for the safe administration of the antibiotic.
D. Potassium 4.4 mEq/L (4.4 mmol/L)
While normal potassium levels are important for overall health, they do not specifically indicate the safety of vancomycin administration. Other factors such as IV access and dosage are more directly related to the safety of vancomycin.
E. Used for prophylaxis
Vancomycin is used for endocarditis prophylaxis in this case, which aligns with the clinical guidelines for preventing infections. Understanding the purpose of the medication supports its appropriate use in the client’s care.
F. Blood urea nitrogen 17 mg/dL (6.07 mmol/L)
An elevated BUN level might indicate renal impairment, which could affect vancomycin metabolism. However, this level alone does not directly address the immediate safety of administering the antibiotic compared to other factors like IV access and dosage.

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A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

Exhibits The nurse collects blood from the client during peripheral IV line placement. What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

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