A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

Choice A Reason:

Assisting the client to the restroom 30 minutes after meals is correct recommendation. This intervention aligns with the natural response of the gastrocolic reflex, which often leads to increased colonic motility after eating. Timing the restroom visit to this period can take advantage of the body's natural tendency to have a bowel movement after meals, potentially aiding in achieving bowel continence.

Choice B Reason:

Limiting the client's physical activity until bowel continence is achieved is not appropriate. Physical activity can actually stimulate bowel function and regularity. Moderate physical activity, as appropriate for the client's condition, can promote regular bowel movements. Restricting physical activity might hinder the overall success of bowel training.

Choice C Reason:

Limiting the client's fluid intake to 1500 mL/dayis not appropriate. Adequate hydration is crucial for bowel health and regularity. Limiting fluid intake could lead to dehydration and constipation, which can exacerbate fecal incontinence. It's important to encourage adequate hydration unless there are specific medical reasons to restrict fluids.

Choice D Reason:

Instructing the client to limit their intake of high-fiber foods is incorrect. High-fiber foods are beneficial for bowel regularity and can help manage fecal incontinence by promoting healthy bowel movements. Limiting high-fiber foods could potentially lead to constipation or exacerbate the issue of fecal incontinence.

Choice A Reason:

Maintaining skin integrity over the blisters is correct. Blisters form as a protective mechanism for the skin underneath. Popping or breaking blisters increases the risk of infection as it exposes the raw skin to bacteria and other contaminants.

Choice B Reason:

Applying ice to the larger blisters is incorrect.

Reason: Applying ice directly to a burn, especially to blisters, can further damage the skin and exacerbate the injury. Ice can cause additional skin damage and can potentially increase pain and delay healing.

Choice C Reason:

Administering ibuprofen for pain is correct. Ibuprofen is an effective over-the-counter pain reliever that can help manage the discomfort caused by a minor burn. It also has anti-inflammatory properties that can reduce swelling associated with burns.

Choice D Reason:

Running cool water over the affected area is correct. Running cool (not cold) water over the burn helps to cool down the burned area, soothes the pain, and helps prevent further damage to the skin. It's recommended to run water over the burn for around 10-15 minutes to effectively cool the area.

Choice E Reason:

Allowing the affected area to remain open to air is incorrect. Keeping a minor burn uncovered can increase the risk of infection as it exposes the burn to external contaminants. Covering the burn with a sterile, non-stick dressing can protect it from further damage and reduce the risk of infection.