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","D","E"]

Explanation

A. Urine-specific gravity greater than 1.030 indicates concentrated urine, suggesting dehydration, not fluid volume excess.
B. A bounding pulse is a sign of fluid volume excess.
C. Swelling at the IV site indicates infiltration, not systemic fluid volume excess.
D. Crackles upon auscultation of the lungs indicate fluid accumulation in the lungs, a sign of fluid volume excess.
E. Pitting edema is a sign of fluid volume excess, indicating fluid retention in the tissues.

A. Provide assistance to bathroom. B. Increase fluids. C. Perform a bladder scan. D. Insert a straight catheter.

Correct Answer is C

Explanation

A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.

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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 assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is C

Explanation

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