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 C
Explanation
A. Prophylactic antibiotics are not routinely given solely because of hemophilia A. They may be indicated based on the client's overall health and the procedure.
B. Packed RBCs are not typically needed for wisdom teeth extractions in clients with hemophilia A, as these procedures do not usually cause significant blood loss.
C. Recombinant factor VIII is the specific treatment for hemophilia A and is administered prior to procedures to prevent bleeding.
D. Fresh frozen plasma contains clotting factors but is not the treatment of choice for hemophilia A. Recombinant factor VIII is preferred due to its specific action and lower risk of complications.
Correct Answer is ["C","D"]
Explanation
A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.
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