A 55-year-old male patient is admitted to the hospital with a diagnosis of thrombocytopenia. Upon assessment, you note petechiae on his lower extremities, and he reports fatigue and occasional nosebleeds. Which of the following interventions should be prioritized for this patient?
Monitor platelet counts and assess for signs of bleeding.
Administer aspirin to manage pain and prevent clot formation.
Administer a diuretic to reduce fluid retention and swelling.
Encourage the patient to increase physical activity to improve circulation.
The Correct Answer is A
Choice A Reason:
Monitoring platelet counts and assessing for signs of bleeding is crucial for managing thrombocytopenia. Thrombocytopenia is characterized by a low platelet count, which increases the risk of bleeding. Regular monitoring helps in detecting any significant drops in platelet levels, allowing for timely interventions to prevent severe bleeding. Assessing for signs of bleeding, such as petechiae, bruising, or nosebleeds, is essential to manage the condition effectively and prevent complications.
Choice B Reason:
Administering aspirin to manage pain and prevent clot formation is not appropriate for patients with thrombocytopenia. Aspirin is an antiplatelet agent that inhibits platelet function, which can exacerbate bleeding tendencies in patients with low platelet counts. Using aspirin in this context could increase the risk of bleeding and is therefore contraindicated.
Choice C Reason:
Administering a diuretic to reduce fluid retention and swelling is not relevant for managing thrombocytopenia. Diuretics are used to manage conditions like hypertension and edema but do not address the underlying issue of low platelet counts. In fact, diuretics can lead to electrolyte imbalances, which may complicate the patient’s condition further.
Choice D Reason:
Encouraging the patient to increase physical activity to improve circulation is not a priority intervention for thrombocytopenia. While physical activity is generally beneficial for overall health, it can increase the risk of trauma and bleeding in patients with low platelet counts. It is important to avoid activities that could lead to injury and bleeding in these patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Administering an alpha-adrenergic blocker is the highest priority intervention for a patient with pheochromocytoma and severe hypertension. Pheochromocytoma causes excessive secretion of catecholamines, leading to severe hypertension. Alpha-adrenergic blockers help to control blood pressure by blocking the effects of these catecholamines, thereby reducing vasoconstriction and lowering blood pressure. This intervention is crucial to prevent hypertensive crises and associated complications such as stroke or myocardial infarction.
Choice B Reason:
Administering intravenous fluids to maintain hydration is important but not the highest priority. While maintaining hydration is essential, it does not directly address the severe hypertension caused by pheochromocytoma. Intravenous fluids can help support overall patient stability but do not specifically target the underlying cause of the hypertension.
Choice C Reason:
Monitoring blood glucose levels every 4 hours is a necessary intervention, especially since pheochromocytoma can cause hyperglycemia due to increased catecholamine levels. However, this intervention is not the highest priority compared to controlling the severe hypertension, which poses a more immediate threat to the patient’s health.
Choice D Reason:
Preparing the patient for immediate surgery to remove the tumor is a critical step in the long-term management of pheochromocytoma. However, surgery is not typically performed until the patient’s blood pressure is stabilized with medications such as alpha-adrenergic blockers. Therefore, while surgery is essential, it is not the immediate priority in the acute management of severe hypertension.
Correct Answer is A
Explanation
Choice A Reason:
Stopping the transfusion immediately and notifying the healthcare provider is the most appropriate initial action when a transfusion reaction is suspected. This action helps to prevent further complications and allows for prompt evaluation and management of the reaction. The nurse should also keep the IV line open with normal saline to maintain venous access.
Choice B Reason:
Administering antipyretics and continuing the transfusion is not appropriate. Continuing the transfusion could exacerbate the reaction and lead to more severe complications. The priority is to stop the transfusion and assess the patient before considering any further interventions.
Choice C Reason:
Slowing down the rate of the transfusion and reassessing in 30 minutes is not a safe approach. Any signs of a transfusion reaction, such as chills and fever, require immediate cessation of the transfusion. Delaying intervention could result in worsening of the patient’s condition.
Choice D Reason:
Continuing the transfusion and monitoring the patient closely is not appropriate. Immediate cessation of the transfusion is necessary to prevent further exposure to the potentially harmful blood product. Monitoring alone is insufficient without stopping the transfusion.
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