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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Place the blood bag in a biohazard bag before discarding: While proper disposal of blood products is important, the immediate priority after stopping the transfusion is to ensure the patient's safety and document the reaction. The blood bag should be sent for analysis, but this action does not address the immediate next steps for patient care.

B. Administer epinephrine subcutaneously: This is not the first action unless the client is experiencing an anaphylactic reaction, which is not indicated in this scenario. The reaction described is more consistent with a febrile non-hemolytic transfusion reaction.

C. Document the reaction in the medical record: This is the most appropriate action following the cessation of the transfusion. Accurate documentation of the reaction ensures that all healthcare providers are informed of the client’s status and the incident, which is critical for ongoing care and safety.

D. Infuse 500 ml. lactated Ringer's IV: While providing IV fluids may be necessary to maintain venous access or manage symptoms, the immediate action after stopping the transfusion should focus on documenting the reaction and notifying the healthcare provider, as appropriate interventions can then be determined.

A. "Advance directives can be signed without legal representation." B. "A social worker will assist you to find affordable legal representation." C. "We can initiate medical care until you get legal assistance in preparing your advance directives." D. "Advance directives can be a verbal agreement between you and your provider until legal review can be obtained."

Correct Answer is A

Explanation

A. "Advance directives can be signed without legal representation.": This statement is accurate and reassuring. Advance directives do not require legal representation to be valid; they can often be completed with forms available from healthcare facilities or online resources.

B. "A social worker will assist you to find affordable legal representation.": While this may be helpful, it may not address the immediate concern that the client has about needing legal representation to create advance directives.

C. "We can initiate medical care until you get legal assistance in preparing your advance directives.": This statement may not align with legal and ethical guidelines regarding treatment without clear advance directives, particularly if the client’s wishes are unknown.

D. "Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.": This is misleading, as advance directives typically need to be documented in writing to be valid and honoured in a medical setting.

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A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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