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. A client who is coughing only is still able to clear the airway by themselves.
B. Inability to make any sounds indicates a complete airway obstruction, requiring the Heimlich maneuver.
C. A client who can whisper has a partial airway obstruction and should be encouraged to continue coughing.
D. A high-pitched inspiratory stridor indicates a partial obstruction, not requiring the Heimlich maneuver but close monitoring.

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

A nurse in a long-term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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