A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect to be decreased?
RBC
Platelets
Granulocytes
WBC
The Correct Answer is B
A. RBC (Red Blood Cells): ITP primarily affects platelet levels, not red blood cells. Therefore, red blood cell counts are not typically decreased in ITP.
B. Platelets: This is the correct answer. ITP is characterized by a low platelet count due to immune-mediated destruction of platelets. A decreased platelet count can lead to an increased risk of bleeding.
C. Granulocytes: While ITP primarily affects platelets, it does not have a direct impact on granulocyte counts. Granulocytes are a type of white blood cell.
D. WBC (White Blood Cells): ITP primarily affects platelets, not white blood cells. Therefore, white blood cell counts are not typically decreased in ITP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Remove the catheter: Removing the catheter may not be the immediate priority. The nurse should focus on preventing further air entry into the circulation and addressing the symptoms.
B. Replace the infusion system: While ensuring that the infusion system is intact is important, it is not the primary action needed to manage an air embolism.
C. Prepare for chest tube insertion: Chest tube insertion is not the primary intervention for an air embolism. The focus should be on preventing the progression of the embolism and providing supportive care.
D. Place the client on his left side in Trendelenburg position: This is the correct answer. Placing the client on the left side in Trendelenburg position is a maneuver used to trap air in the right atrium, preventing it from traveling to the pulmonary artery. The left side position helps to prevent the air from traveling to the right ventricle and into the pulmonary artery, reducing the risk of further complications.
Correct Answer is C
Explanation
A. Flexing her ankles: Ankle flexion exercises and periodic ankle flexion are encouraged to promote blood circulation and prevent venous stasis, which can contribute to the development of venous thromboembolism (VTE).
B. Elevating her feet: Elevating the feet can also help prevent venous stasis and promote blood circulation. It is a recommended action to reduce the risk of VTE.
C. Massaging her legs: This is the correct answer. Massage of the legs, particularly deep tissue massage, can dislodge blood clots and increase the risk of embolization, including the risk of venous thromboembolism.
D. Ambulating soon after surgery: Early ambulation is an important preventive measure for VTE. It helps stimulate blood flow and prevents venous stasis. Encouraging the client to ambulate as soon as possible after surgery is a recommended practice.
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