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:
Implementing strict hand hygiene protocols is the most critical intervention to prevent infection in patients with acute lymphoblastic leukemia (ALL). Patients with ALL are highly susceptible to infections due to their compromised immune systems, which result from both the disease and the chemotherapy treatment. Hand hygiene is a fundamental practice in infection control, significantly reducing the transmission of pathogens. Ensuring that all healthcare providers, patients, and visitors adhere to strict hand hygiene protocols can greatly minimize the risk of infections.
Choice B Reason:
Administering prophylactic antibiotics regularly can help prevent infections, but it is not the most critical intervention. Overuse of antibiotics can lead to antibiotic resistance and other complications. While antibiotics are important in managing infections, they should be used judiciously and in conjunction with other infection control measures, such as hand hygiene.
Choice C Reason:
Encouraging the patient to eat a high-protein diet is beneficial for overall health and recovery, but it does not directly prevent infections. A high-protein diet can help maintain muscle mass and support the immune system, but it is not a primary infection control measure.
Choice D Reason:
Limiting the patient’s fluid intake is not relevant to preventing infections in patients with ALL. Adequate hydration is important for overall health and helps in the management of side effects from chemotherapy. Fluid restriction is not a standard intervention for infection prevention in this context.
Correct Answer is A
Explanation
Choice A Reason:
Tilting the head to the side and pulling the earlobe up and back is the recommended method for adults to straighten the ear canal, allowing the drops to flow directly into the ear canal and reach the site of infection effectively. This method ensures that the medication is properly administered and can work effectively to treat the infection.
Choice B Reason:
Laying flat on your back and placing the drops on a cotton ball before inserting it into the ear canal is not a recommended method for administering ear drops. This method can prevent the medication from reaching the ear canal properly and may not be as effective in treating the infection. Additionally, using a cotton ball can absorb the medication, reducing its effectiveness.
Choice C Reason:
Tilting the head to the side and pulling the earlobe down and back is the correct method for administering ear drops to children under three years old. For adults, this method is not recommended as it does not straighten the ear canal properly, which can prevent the medication from reaching the site of infection effectively.
Choice D Reason:
Tilting the head forward and pulling the earlobe up and forward is not a recommended method for administering ear drops. This method does not properly straighten the ear canal and can prevent the medication from reaching the site of infection. It is important to follow the correct technique to ensure the medication is effective.
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