When caring for a client diagnosed with thrombocytopenia, the nurse should plan to:
encourage vigorous tooth brushing with a soft bristle toothbrush.
avoid needle sticks or other invasive procedures as much as possible.
hold all stool softeners and laxatives until otherwise ordered.
obtain a low temperature every 8 hours.`
The Correct Answer is B
Choice A reason: The nurse should not encourage vigorous tooth brushing with a soft bristle toothbrush. Thrombocytopenia is a condition where the blood has a low number of platelets, which are cells that help with clotting. ¹ Vigorous tooth brushing can cause bleeding of the gums, which can be hard to stop in a client with thrombocytopenia. The nurse should advise the client to use a soft sponge or swab to clean the teeth and mouth gently.
Choice B reason: The nurse should avoid needle sticks or other invasive procedures as much as possible. Needle sticks and other invasive procedures can cause bleeding, bruising, or infection in a client with thrombocytopenia. ¹ The nurse should use the smallest gauge needle possible, apply pressure for at least 10 minutes after the procedure, and monitor the site for any signs of bleeding or infection. The nurse should also avoid unnecessary blood draws or injections, and use non-invasive methods whenever possible.
Choice C reason: The nurse should not hold all stool softeners and laxatives until otherwise ordered. Stool softeners and laxatives can help prevent constipation and straining, which can cause hemorrhoids or anal fissures in a client with thrombocytopenia. ¹ The nurse should encourage the client to take stool softeners and laxatives as prescribed, drink plenty of fluids, and eat high-fiber foods to promote regular bowel movements.
Choice D reason: The nurse should not obtain a low temperature every 8 hours. A low temperature is not a relevant or accurate measurement for a client with thrombocytopenia. The nurse should obtain a normal temperature, which is around 98.6°F (37°C), using a non-invasive method, such as an oral or tympanic thermometer. ² The nurse should avoid using a rectal thermometer, as it can cause bleeding or infection in a client with thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Total cholesterol is not the best indicator of the effectiveness of simvastatin, a drug that lowers cholesterol levels and reduces the risk of cardiovascular disease. ¹ Total cholesterol includes both LDL and HDL (high density lipoprotein), which have opposite effects on the heart and blood vessels. ² The normal range of total cholesterol for adults is less than 200 mg/dL, but this does not reflect the balance between LDL and HDL.
Choice B reason: Blood pressure is not directly related to the effectiveness of simvastatin, although high blood pressure and high cholesterol are both risk factors for cardiovascular disease. ³ Simvastatin does not lower blood pressure, but it may prevent or slow down the development of atherosclerosis, which is the narrowing and hardening of the arteries due to plaque buildup. ¹ The normal range of blood pressure for adults is less than 120/80 mmHg.
Choice C reason: Serum triglycerides are another type of fat in the blood that can contribute to cardiovascular disease. ² Simvastatin can lower triglyceride levels, but this is not its main effect. ¹ The normal range of serum triglycerides for adults is less than 150 mg/dL.
Choice D reason: LDL is the main target of simvastatin therapy, as it is the "bad" cholesterol that can cause plaque buildup and damage the arteries. ¹ Simvastatin works by inhibiting an enzyme that produces LDL in the liver. The optimal level of LDL for adults is less than 100 mg/dL, and even lower for those with high risk of cardiovascular disease. ² A LDL level of 90 mg/dL indicates that the client's current dose of simvastatin has been effective.
Correct Answer is C
Explanation
Choice A reason: Limiting the intake of citrus juices is not related to the teaching about hydrochlorothiazide. Citrus juices are rich in vitamin C, which has no significant interaction with hydrochlorothiazide. The client does not need to avoid or limit citrus juices unless they have other medical conditions that require dietary restrictions.
Choice B reason: Eating bananas daily to lower the potassium level is a wrong statement. Bananas are high in potassium, which is a mineral that hydrochlorothiazide can deplete from the body. The client may need to increase their potassium intake or take a potassium supplement to prevent hypokalemia, a condition of low potassium level that can cause muscle weakness, cramps, and arrhythmias.
Choice C reason: Taking the pill each day in the morning is the correct statement. Hydrochlorothiazide is a diuretic that increases the urine output and reduces the blood volume and pressure. The client should take the pill in the morning to avoid nocturia, which is frequent urination at night that can disrupt the sleep quality and increase the risk of falls.
Choice D reason: Taking the pill each day after dinner is not the best statement. Hydrochlorothiazide can cause diuresis, which is increased urine production and excretion. Taking the pill after dinner can lead to nocturia, which is frequent urination at night that can interfere with the sleep cycle and cause fatigue and irritability. The client should take the pill in the morning to prevent nocturia and its complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.