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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.

B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.

C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.

D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.

A. Folate B. Vitamin C C. Vitamin B12 D. Iron

Correct Answer is C

Explanation

A. Folate: Folate is important for red blood cell production but does not address the Vitamin B12 deficiency seen in pernicious anemia.

B. Vitamin C: Vitamin C does not impact pernicious anemia as it is not involved in Vitamin B12 absorption.

C. Vitamin B12: Pernicious anemia occurs due to a lack of intrinsic factor, which is necessary for Vitamin B12 absorption. After a total gastrectomy, intrinsic factor is no longer produced, requiring Vitamin B12 supplementation.

D. Iron: Iron deficiency anemia is different from pernicious anemia, which specifically requires Vitamin B12 supplementation.

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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?

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Naxlex Comprehensive Predictor Exams

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