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 ["1610"]
Explanation
Solution:
- Convert ounces to milliliters (1 oz = 30 mL):
- Coffee: 8 oz × 30 mL = 240 mL
- Juice: 3 oz × 30 mL = 90 mL
- Soda: 12 oz × 30 mL = 360 mL
- Calculate water intake:
- Initial pitcher: 800 mL
- Remaining: 200 mL
- Water intake = 800 mL - 200 mL = 600 mL
- Calculate IV fluids intake:
- IV rate: 40 mL/hr
- Time: 8 hours
- IV fluids = 40 mL/hr × 8 hrs = 320 mL
- Total intake:
- 240 mL (coffee) + 90 mL (juice) + 360 mL (soda) + 600 mL (water) + 320 mL (IV) = 1610 mL
Answer: 1610 mL
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