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?

Check the client for ecchymosis.

Initiate protective isolation for the client.

Administer ibuprofen for mild headache.

Instruct the client to shave with a disposable razor.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Checking the client for ecchymosis is appropriate. Thrombocytopenia increases the risk of bleeding and bruising, so monitoring for ecchymosis (bruising) is essential to detect any signs of bleeding. Ecchymosis can occur more easily in individuals with low platelet counts.
Choice B Reason:
Initiating protective isolation for the client is typically unnecessary solely due to thrombocytopenia. Protective isolation is generally for clients with conditions that compromise their immune system or make them more susceptible to infections.
Choice C Reason:
Administering ibuprofen for a mild headache might not be advisable in someone with thrombocytopenia because ibuprofen can affect platelet function and potentially increase the risk of bleeding.
Choice D Reason:
Instructing the client to shave with a disposable razor isn't recommended because using a sharp blade can increase the risk of cuts and bleeding in someone with a low platelet count. Using an electric razor or avoiding shaving might be safer options to prevent injury and bleeding.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason:
Absence of Chvostek's sign is a wrong indication. Chvostek's sign is a twitching of facial muscles in response to tapping the facial nerve and is typically associated with low blood calcium levels (hypocalcemia). It's not directly related to hyperglycemia or high blood sugar levels. Hyperglycemia refers to high blood sugar levels, commonly associated with diabetes mellitus.
Choice B Reason:
Presence of Kussmaul respirations is a right indication. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in individuals with diabetic ketoacidosis (DKA), a severe complication of diabetes characterized by significantly high blood sugar levels and the presence of ketones in the blood and urine. This type of breathing pattern is the body's attempt to compensate for the acidic state caused by high blood sugar and the buildup of ketones.
Choice C Reason:
Presence of diaphoresis is a wrong indication. Diaphoresis refers to excessive sweating, which can occur due to various reasons such as physical activity, heat, stress, or certain medical conditions. While hyperglycemia can cause symptoms like increased thirst and frequent urination, diaphoresis alone is not a specific indicator of high blood sugar levels.
Choice D Reason:
Absence of urinary ketones is a wrong indication. The presence of urinary ketones indicates the body is breaking down fat for energy, which commonly occurs during periods of insufficient insulin (such as in hyperglycemia or diabetic ketoacidosis). However, the absence of urinary ketones doesn't necessarily rule out hyperglycemia. It's possible for hyperglycemia to be present without ketones in the urine, especially in the early stages or when the body is still managing blood sugar levels without significant ketone production.

A. LDL B. INR C. BUN D. Hct

Correct Answer is B

Explanation

Choice A Reason:

LDL (Low-Density Lipoprotein) is incorrect. This is a type of cholesterol and is not specifically monitored in relation to warfarin therapy.

Choice B Reason:

INR (International Normalized Ratio) is correct. Warfarin is an anticoagulant medication, and its dosage needs to be adjusted based on the INR levels. INR monitoring helps assess the clotting tendency of the blood and ensures that the dosage of warfarin is within the therapeutic range to prevent blood clots without causing excessive bleeding.

Choice C Reason:

BUN (Blood Urea Nitrogen) is incorrect. This value is primarily used to assess kidney function and is not directly related to monitoring warfarin therapy.

Choice D Reason:

Hct (Hematocrit) is incorrect. This measures the percentage of red blood cells in the blood and is not directly related to monitoring warfarin therapy for atrial fibrillation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?

Correct Answer is B

Explanation

A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?

Correct Answer is B

Explanation

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates the colostomy is functioning properly?

A nurse is reinforcing teaching with a client who is taking enoxaparin. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?

A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?

A nurse is reinforcing teaching for a client who was admitted with an exacerbation of COPD. Which of the following should the nurse include in the client teaching?

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?