A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements indicates an understanding of the teaching?
"I will use an enema to manage my constipation."
"I will remove my shoes when I'm inside my house."
"I will wipe my nose instead of blowing it."
"I will floss between my teeth every time I brush."
The Correct Answer is C
A) "I will use an enema to manage my constipation.": This statement is concerning because enemas can cause trauma to the rectal mucosa, which may lead to bleeding in a client with thrombocytopenia. Therefore, this action is not advisable and indicates a lack of understanding of safe practices.
B) "I will remove my shoes when I'm inside my house.": While removing shoes can help maintain cleanliness, it does not directly relate to managing thrombocytopenia or preventing bleeding. This statement does not reflect an understanding of the specific precautions needed for a client with low platelet counts.
C) "I will wipe my nose instead of blowing it.": This statement demonstrates an understanding of the need to minimize trauma to the nasal passages. Blowing the nose can increase the risk of bleeding in individuals with thrombocytopenia, so wiping is a safer alternative.
D) "I will floss between my teeth every time I brush.": Flossing can be harmful for a person with thrombocytopenia, as it may cause gum bleeding. Clients are often advised to avoid flossing to reduce the risk of bleeding, indicating that this statement reflects a misunderstanding of appropriate oral care practices for their condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. "The estimated blood loss was 250 milliliters":
This is the most appropriate information to include in the hand-off report. The estimated blood loss (EBL) is a key piece of post-operative information that can help guide nursing care, including monitoring for signs of hypovolemia or shock, and assessing for the need for interventions like fluid resuscitation or blood transfusion. It's clinically relevant and helps the nurse on the medical-surgical unit understand the client's post-operative status and needs.
Correct Answer is B
Explanation
A) Fetal anemia:Fetal anemia typically causes tachycardia (increased heart rate) rather than bradycardia (decreased heart rate). It is not a common cause of fetal bradycardia.
B) Maternal hypoglycemia:Maternal hypoglycemia can lead to decreased glucose availability for the fetus, resulting in fetal bradycardia. It is important to monitor and manage maternal blood glucose levels to ensure adequate fetal oxygenation and prevent bradycardia.
C) Chorioamnionitis:Chorioamnionitis, an infection of the amniotic fluid and membranes, usually causes fetal tachycardia rather than bradycardia. It is associated with an increased fetal heart rate due to the inflammatory response.
D) Maternal fever:Maternal fever is more likely to cause fetal tachycardia due to the increased metabolic rate and oxygen demand. It is not typically associated with fetal bradycardia.
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