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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Rolling the client to one side of the bed is an appropriate action to change the linens.
B. Reaching over the bed to straighten the fitted sheet can cause strain and potential injury to the AP's back and should be corrected.
C. Lowering the side rail on the side of the bed closest to the AP is necessary for changing the linens safely.
D. Raising the bed to waist level is an appropriate action to ensure proper body mechanics and prevent injury.

A. “I’ll take salt tablets when I work outdoors in the summer." B. "I need to drink extra fluids when working outside in hot weather.” C. “I’ll move to a cool environment if I notice that I'm feeling confused" D. “I should take acetaminophen (Tylenol) if I start to feel too warm.”

Correct Answer is B

Explanation

A. Taking salt tablets can lead to electrolyte imbalances and is not recommended for managing heat-related issues.
B. Drinking extra fluids helps prevent dehydration and is an effective measure to prevent heat-related illness.
C. Moving to a cool environment when feeling confused is important but is a reactive measure rather than preventive teaching.
D. Taking acetaminophen for feeling too warm does not address the underlying issue of heat-related illness and is not appropriate discharge teaching for this situation.

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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

A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Correct Answer is B

Explanation

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?

Correct Answer is B

Explanation

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