A 55-year-old patient with thrombocytopenia is scheduled for a venipuncture procedure. Which of the following actions should the nurse take to minimize the risk of bleeding?
Instruct the patient to elevate the arm above the heart immediately after the procedure.
Apply firm pressure to the site for at least 10 minutes after the procedure.
Avoid using a tourniquet during the procedure.
Use a larger gauge needle to ensure quicker blood flow.
The Correct Answer is B
Choice A: Instruct the patient to elevate the arm above the heart immediately after the procedure
Elevating the arm above the heart can help reduce blood flow to the area, potentially minimizing bleeding. However, this method alone is not sufficient to ensure proper hemostasis, especially in patients with thrombocytopenia. Applying direct pressure to the puncture site is more effective in stopping bleeding and preventing hematoma formation.
Choice B: Apply firm pressure to the site for at least 10 minutes after the procedure
Applying firm pressure to the venipuncture site is crucial in patients with thrombocytopenia to ensure proper clotting and prevent bleeding. This method helps in forming a stable clot at the puncture site, reducing the risk of prolonged bleeding and hematoma formation. Given the patient’s low platelet count, maintaining pressure for an extended period is essential to achieve hemostasis.
Choice C: Avoid using a tourniquet during the procedure
While avoiding a tourniquet might seem beneficial to reduce pressure on the veins, it is not a standard practice to minimize bleeding risk in thrombocytopenic patients. Tourniquets are typically used to make veins more prominent for easier access during venipuncture. The key to minimizing bleeding is proper post-procedure care, such as applying firm pressure to the site.
Choice D: Use a larger gauge needle to ensure quicker blood flow
Using a larger gauge needle is not advisable for patients with thrombocytopenia. Larger needles can cause more trauma to the vein, increasing the risk of bleeding and hematoma formation. Instead, using the smallest gauge needle that can effectively draw blood is recommended to minimize vein damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Administering intravenous acetazolamide is a critical intervention for acute narrow-angle glaucoma. Acetazolamide is a carbonic anhydrase inhibitor that reduces the production of aqueous humor, thereby lowering intraocular pressure (IOP) quickly. Reducing IOP is essential to prevent optic nerve damage and preserve vision. Normal IOP ranges from 10 to 21 mmHg, and in acute narrow-angle glaucoma, it can exceed 30 mmHg. Rapid reduction of IOP is crucial to alleviate symptoms and prevent further complications.
Choice B Reason:
Applying warm compresses to the affected eye is not an appropriate intervention for acute narrow-angle glaucoma. Warm compresses may provide temporary relief for some eye conditions, but they do not address the underlying issue of elevated intraocular pressure. In fact, warm compresses can potentially increase blood flow to the eye, which might exacerbate the condition.
Choice C Reason:
Encouraging the patient to drink plenty of fluids to stay hydrated is generally good advice for overall health, but it is not a prioritized intervention for acute narrow-angle glaucoma. Hydration does not directly impact intraocular pressure or alleviate the acute symptoms of glaucoma. The primary focus should be on reducing IOP to prevent optic nerve damage.
Choice D Reason:
Administering a mydriatic agent to dilate the pupil is contraindicated in acute narrow-angle glaucoma. Mydriatic agents can worsen the condition by further narrowing the anterior chamber angle, increasing intraocular pressure, and potentially causing more damage to the optic nerve. It is crucial to avoid pupil dilation in this scenario.
Correct Answer is A
Explanation
Choice A Reason:
Allowing the client to keep her hearing aids in is crucial for effective communication between the nurse and the client. Hearing aids help the client understand instructions and respond appropriately, which is essential for ensuring the client’s safety and comfort before surgery. According to preoperative guidelines, patients with hearing impairments should be allowed to use their hearing aids until they are taken to the operating room. This practice helps reduce anxiety and ensures that the client can hear and understand all preoperative instructions and consent information.
Choice B Reason:
Allowing the client to consume clear liquids up to the time of surgery is generally not recommended. Preoperative fasting guidelines typically require patients to stop consuming clear liquids at least two hours before surgery to reduce the risk of aspiration during anesthesia. Therefore, this option is not appropriate for ensuring the client’s safety.
Choice C Reason:
Allowing the client to take her morning vitamins is not advisable without specific instructions from the surgical team. Some vitamins and supplements can interact with anesthesia or increase the risk of bleeding during surgery. It is essential to follow the surgical team’s guidelines regarding medication and supplement intake before surgery.
Choice D Reason:
Allowing the client to keep her tongue stud in is not recommended. All jewelry and body piercings should be removed before surgery to prevent complications such as electrical burns during the use of electrocautery devices or interference with airway management. Removing the tongue stud is necessary to ensure the client’s safety during the procedure.
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