A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Measure abdominal girth twice weekly.

Monitor for the presence of WBCs in the urine.

Apply pressure to needlestick sites for 10 min.

Assess core temperatures using a rectal thermometer.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Measuring abdominal girth is not directly related to thrombocytopenia management.
B. Monitoring for WBCs in the urine is not related to thrombocytopenia.
C. Applying pressure to needlestick sites for 10 minutes helps prevent bleeding, which is crucial for clients with thrombocytopenia.
D. Using a rectal thermometer can increase the risk of bleeding and should be avoided in clients with thrombocytopenia.

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Correct Answer is B

Explanation

A. Emphasizing the significance of the information may not address the cultural behavior of avoiding direct eye contact.
B. Continuing with the discussion respects the client's cultural behavior, as some cultures view direct eye contact as disrespectful.
C. Stopping the instructions to see what is on the floor may misunderstand the client's cultural behavior.
D. Moving closer for eye contact may make the client uncomfortable if their culture views direct eye contact as inappropriate.

A. At the nurses' station while reviewing the provider's prescription B. At the time of documentation C. In the area where the nurse obtained the medication D. At the client's bedside before administration

Correct Answer is D

Explanation

Rationale:
A. Reviewing at the nurses' station ensures understanding but is not the final check.
B. Documentation occurs after administration and is not part of the final check.
C. Checking the medication in the area where it was obtained is important but not the final check.
D. Performing the final check at the client's bedside before administration ensures the correct medication is given to the correct client, preventing medication errors.

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A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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