The nurse is caring for a client with severe thrombocytopenia who is scheduled for a bone marrow biopsy.
The provider prescribes a platelet transfusion for the client. When should the nurse anticipate administering the platelets?
Slowly during the bone marrow biopsy procedure.
Immediately following the completion of the bone marrow biopsy.
Immediately before the start of the bone marrow biopsy.
1 to 2 hours before the bone marrow biopsy begins.
The Correct Answer is C
The clinical scenarios involve managing procedural safety in hematology, post-surgical electrolyte monitoring, emergency cardiac stabilization for potassium imbalance, and surgical intervention for burn-induced compartment syndrome. Knowledge of hemostasis, calcium metabolism, membrane potential stabilization, and tissue perfusion mechanics is required to provide safe nursing care.
Choice A rationale
Administering platelets during a procedure is impractical and increases the risk of bleeding before the infusion takes effect. Platelets must be present in the vascular system prior to tissue trauma to facilitate immediate clot formation at the site.
Choice B rationale
Post-procedural administration fails to address the high risk of hemorrhage during the biopsy itself. In severe thrombocytopenia, where counts are often below 20,000 cells/uL, the primary goal is pre-emptive stabilization to prevent uncontrolled internal bleeding.
Choice C rationale
Infusing platelets immediately before the biopsy ensures peak circulating levels during the most invasive phase. This timing optimizes the aggregation of platelets at the puncture site, mitigating the risk of hematoma or severe hemorrhage in high-risk patients.
Choice D rationale
Platelets have a short half-life and are rapidly consumed or sequestered. Administering them 1 to 2 hours early may lead to decreased efficacy at the actual time of the biopsy, increasing the risk of procedural bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Evaluating a patient with liver failure involves understanding the biosynthetic pathways of coagulation. The liver produces vitamin K dependent clotting factors, and monitoring laboratory trends is essential to assess the severity of coagulopathy and the risk for spontaneous internal bleeding.
Choice A rationale
Urine output monitoring assesses renal perfusion and fluid balance, which is important in liver failure due to the risk of hepatorenal syndrome. However, it does not directly measure the liver ability to synthesize the essential factors needed for clotting.
Choice B rationale
Oxygen saturation measures the percentage of hemoglobin bound to oxygen in the blood. While respiratory status is important, it is not the priority assessment for a patient specifically at risk for hemorrhage due to impaired clotting factor synthesis.
Choice C rationale
Blood pressure can indicate hemodynamic stability and signs of shock if a bleed has already occurred. However, it is a late indicator of hemorrhage and does not provide information regarding the actual physiological capacity for blood coagulation.
Choice D rationale
The liver synthesizes factors I, II, VII, IX, and X. PT and INR directly measure the extrinsic pathway of coagulation. A normal PT is 11 to 13.5 seconds, and a normal INR is 0.8 to 1.1.
Correct Answer is C
Explanation
Maintaining airway patency while managing intracranial pressure requires a balance between oxygenation and avoiding spikes in pressure. Knowledge of airway management and the physiological effects of hypoxia on cerebral edema is essential for prioritizing immediate life-saving interventions.
Choice A rationale
Elevating the head of the bed to 30 to 45 degrees promotes venous drainage and reduces intracranial pressure. While a standard nursing intervention for these patients, it does not clear an obstructed airway caused by pooled secretions.
Choice B rationale
Limiting stimulation helps prevent sudden increases in intracranial pressure caused by environmental stress. Although important for neurological stability, it is not the priority when the client's airway is compromised by secretions that prevent adequate ventilation.
Choice C rationale
Suctioning is necessary to clear the airway and maintain oxygenation. Hypoxia and hypercapnia are potent vasodilators that significantly increase intracranial pressure. Clearing the airway is the first priority, though it should be done quickly to minimize stimulation.
Choice D rationale
Sedatives may be used to reduce metabolic demand and blunt the intracranial pressure response to noxious stimuli like suctioning. However, administration takes time and does not physically remove the secretions causing the immediate airway obstruction..
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