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.
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Related Questions
Correct Answer is A
Explanation
A. Checking the patency of the client's airway is the priority action because maintaining a clear airway is crucial during a seizure to ensure adequate oxygenation and prevent aspiration.
B. Determining the poison is important but not the immediate priority during a seizure.
C. Positioning the client side-lying is important to prevent aspiration, but the first action should be to ensure the airway is clear.
D. Identifying the amount of poison ingested is important for treatment but not the immediate priority during a seizure.
Correct Answer is C
Explanation
A. Hiccups are not a common adverse effect of morphine.
B. Heartburn is not a common adverse effect of morphine.
C. Orthostatic hypotension is a known adverse effect of morphine due to its potential to cause vasodilation and lower blood pressure, especially when the client changes positions.
D. Diarrhea is not a common adverse effect of morphine; constipation is more likely.
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