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 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.

A. A client who had a hemi-colectomy and placement of a colostomy B. A client who has a chest tube following a fall from a ladder C. A client receiving continuous enteral feeding through NG tube D. A client who Crohn's disease and has an ileostomy

Correct Answer is C

Explanation

A. A client with a hemi-colectomy and colostomy is not at highest risk for aspiration.
B. A client with a chest tube may have respiratory issues but is not at the highest risk for aspiration.
C. A client receiving continuous enteral feeding through an NG tube is at the highest risk for aspiration due to the risk of feeding contents entering the airway.
D. A client with Crohn's disease and an ileostomy is not at the highest risk for aspiration.

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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

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