The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?
Report fever to MD ASAP
Use soft toothbrush with oral care
Drink hot liquids TID
Recommend Straight edge razor for shaving
The Correct Answer is B
A. Report fever to MD ASAP: While fever in any immunocompromised patient should be reported, it does not directly address precautions related to low platelet counts and bleeding risks.
B. Use a soft toothbrush with oral care: With a low platelet count, the patient is at risk for bleeding. Using a soft toothbrush minimizes the risk of gum injury and bleeding, a critical safety measure for thrombocytopenic patients.
C. Drink hot liquids TID: Hot liquids are not recommended as they may cause mouth or esophageal burns, increasing bleeding risk if the mucosa is damaged. Tepid or cold fluids are safer.
D. Recommend straight edge razor for shaving: Patients with low platelets should use an electric razor to avoid cuts, as any bleeding is harder to control in thrombocytopenic individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Progressive increase in platelet production: In DIC, platelets are rapidly consumed, not increased, due to widespread clotting in the blood vessels.
B. Excessive thrombosis and bleeding: DIC is a complex condition where there is widespread activation of the clotting cascade, leading to excessive clotting and subsequent depletion of platelets and clotting factors, resulting in both thrombosis and bleeding.
C. Immediate sodium and fluid retention: Sodium and fluid retention are not specific findings in DIC; they may occur in cases of renal or heart failure but are unrelated to the clotting issues in DIC.
D. Increased clotting factors: In DIC, clotting factors are depleted as they are used up in widespread clotting, leading to bleeding when factors are exhausted.
Correct Answer is B
Explanation
A. Initiate a 2 L/day fluid restriction: Hydration is crucial in sickle cell crisis to prevent further sickling and reduce blood viscosity. A fluid restriction would worsen the crisis.
B. Assist with administering a blood transfusion: Blood transfusions are commonly given during sickle cell crisis to manage anemia and reduce the concentration of sickled cells, which can improve oxygen delivery and relieve pain.
C. Withhold opioids to avoid dependence: Pain management, including opioids if needed, is essential during a sickle cell crisis. The risk of dependence is secondary to controlling acute pain.
D. Encourage exercise: Rest is recommended during a crisis to reduce oxygen demand and prevent further sickling. Exercise would increase oxygen needs, worsening the crisis.
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