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 B

Explanation

A. Positioning the wrapped package with the outer flap away helps maintain sterility when opening.
B. Holding gauze packages 15 cm (6 in) above the sterile field is incorrect; sterile items should be held at least 15 cm (6 in) above the sterile field to maintain sterility.
C. Holding a bottle of solution with the label away from the palm helps prevent contamination.
D. Wearing sterile gloves when handling sterile items on the sterile field helps maintain sterility.

A. PT 45 seconds B. Platelets 190,000/mm3 C. Hct 44% D. Hgb 16 g/dL

Correct Answer is A

Explanation

A. A PT of 45 seconds is prolonged and indicates a potential risk of bleeding due to excessive anticoagulation with warfarin. The nurse should notify the provider for further evaluation and adjustment of the warfarin dosage.
B. Platelets within the normal range (150,000-400,000/mm3) are adequate and do not require immediate provider notification.
C. Hematocrit of 44% is within the normal range for adults and does not indicate an urgent need for provider notification.
D. Hemoglobin of 16 g/dL is within the normal range for adults and does not require immediate provider notification.

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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

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