A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for:

Fatigue

Side effects of immunosuppressants

Thrombocytopenia

Infection

Answer and Explanation

The Correct Answer is C

Choice A reason: Fatigue is a common symptom of ITP but is not the primary concern for monitoring, as it does not directly indicate the severity of the condition.

Choice B reason: While monitoring for side effects of immunosuppressants is important, it is not the priority concern. The primary issue in ITP is the low platelet count, which poses a risk of bleeding.

Choice C reason: Thrombocytopenia, or low platelet count, is the hallmark of ITP and the main concern for monitoring, as it increases the risk of bleeding and bruising.

Choice D reason: Infection is a risk due to the potential use of immunosuppressants in treatment; however, the immediate concern in ITP management is the platelet count and associated bleeding risk.

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Correct Answer is B

Explanation

Choice A reason: Hypernatremia is not typically associated with prerenal AKI. Prerenal AKI is characterized by conditions that reduce blood flow to the kidneys, not directly causing high sodium levels.

Choice B reason: This choice is correct. Hyperkalemia, which is a high level of potassium in the blood, is a common electrolyte imbalance seen in prerenal AKI due to decreased kidney function and the inability to excrete potassium.

Choice C reason: Hypophosphatemia, or low levels of phosphate in the blood, is not a typical finding in prerenal AKI.

Choice D reason: Hypercalcemia, or high levels of calcium in the blood, is not commonly associated with prerenal AKI. It is more often related to other conditions such as hyperparathyroidism or malignancy.

A. Medication administration record B. Identification wristband C. Order sheet D. Chart

Correct Answer is B

Explanation

Choice A reason: The medication administration record is an important document, but it is not the primary source for verification before administering blood products. It is used to record the administration after the fact.

Choice B reason: The identification wristband is the priority source for verification. It contains the client's essential information, such as name and hospital ID, which must match the blood product label to ensure patient safety⁸.

Choice C reason: The order sheet contains the physician's orders, which is crucial for verifying what has been prescribed but is secondary to the identification wristband for the actual administration process.

Choice D reason: The chart contains a comprehensive record of the client's medical history and care but is not the primary source for verification when administering blood products.

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A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

Explanation

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