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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.
Correct Answer is D
Explanation
A. Sickle cell anemia typically presents with hemolytic crises and sickle-shaped red blood cells, not necessarily heavy menstrual bleeding.
B. Folic acid deficiency anemia can cause macrocytic anemia but is less likely to cause heavy menstrual bleeding as the primary symptom.
C. Pernicious anemia is due to vitamin B12 deficiency and typically presents with neurological symptoms along with anemia, not necessarily heavy menstrual bleeding.
D. Iron-deficiency anemia commonly presents with weakness, fatigue, and heavy menstrual bleeding due to inadequate iron for red blood cell production.
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