A nurse is preparing to administer an IM injection for an infant. Which of the following actions should the nurse take?

Rationale:

A. "I will remove my shoes when I'm inside my house.": While keeping the environment safe from tripping hazards is good for general safety, removing shoes does not specifically prevent bleeding, which is the main concern in thrombocytopenia. This action does not demonstrate understanding of bleeding precautions.

B. "I will floss between my teeth every time I brush": Flossing can cause gum bleeding, which is risky for clients with low platelet counts. Effective teaching would emphasize avoiding activities that may cause mucosal or skin bleeding, so this statement reflects a misunderstanding.

C. "I will wipe my nose instead of blowing it.": Gentle wiping reduces the risk of nasal bleeding, which is important in clients with thrombocytopenia. This statement shows the client understands the need to minimize trauma to areas prone to bleeding and demonstrates correct application of bleeding precautions.

D. "I will use an enema to manage my constipation.": Using an enema can cause mucosal trauma and rectal bleeding, which is unsafe for clients with thrombocytopenia. Safe constipation management would involve gentle measures such as stool softeners and increased hydration.

Rationale:

A. Clarify the source of the referral: Before taking any action, the nurse must first clarify the referral source to understand why the visit is needed, the client’s health status, and any specific concerns or priorities. This ensures the nurse has accurate and complete information to plan the visit safely and effectively.

B. Contact the family by phone: While contacting the family is necessary to arrange the visit, it should occur only after the nurse understands the purpose of the referral and any special considerations to communicate relevant information.

C. Implement the nursing process: Implementing the nursing process requires assessment and planning. The nurse cannot proceed to intervention without first obtaining information about the referral and preparing appropriately.

D. Schedule a time for the home visit: Scheduling is important for logistics, but it should occur after clarifying the referral and understanding the family’s needs to ensure the visit is purposeful and safe.