A nurse is caring for a child who has a tracheostomy.
After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

Choice A rationale

Elevated WBC is not a primary manifestation of idiopathic thrombocytopenic purpura (ITP). ITP is an autoimmune disorder characterized by platelet destruction, leading to thrombocytopenia. While some immune disorders might show WBC abnormalities, the hallmark of ITP is low platelet count, not an elevated white blood cell count, which would suggest infection or another inflammatory process.

Choice B rationale

Fatigue is a common non-specific symptom that can be present in many conditions, including anemia, which may result from significant bleeding associated with severe thrombocytopenia in ITP. However, it is not the most direct or specific manifestation that a nurse would primarily monitor for in ITP, as other more objective signs of bleeding are more indicative of the disease's active state.

Choice C rationale

Ecchymosis, which refers to subcutaneous extravasation of blood resulting in bruising, is a direct manifestation of low platelet counts in idiopathic thrombocytopenic purpura (ITP). Reduced platelet aggregation and adhesion impair the body's ability to form clots, leading to spontaneous bleeding into the skin and other tissues, making ecchymosis a key indicator of the disease's activity.

Choice D rationale

Fever is not a typical manifestation of idiopathic thrombocytopenic purpura (ITP) itself. While a patient with ITP might develop a fever if they have an underlying infection or another co-occurring illness, fever is not directly caused by the autoimmune destruction of platelets characteristic of ITP. Monitoring for fever would be more relevant in the context of infection or other systemic inflammatory processes.

Choice A rationale

While monitoring clients is important, placing a client with active tuberculosis in a room within view of the nurses' station does not address the fundamental need for infection control. Tuberculosis is an airborne disease requiring specific environmental controls to prevent transmission, which this choice does not provide.

Choice B rationale

A room with air exhaust directly to the outdoor environment, often called a negative pressure room or airborne infection isolation room (AIIR), is essential for clients with active tuberculosis. This design prevents airborne mycobacteria from circulating within the healthcare facility, directing them outside to reduce the risk of transmission to others.

Choice C rationale

Placing a client with active tuberculosis in the ICU is generally unnecessary unless their clinical condition warrants critical care, such as respiratory failure. The primary concern for tuberculosis is airborne isolation, which can be achieved on a regular medical-surgical unit with appropriate room design and ventilation, not necessarily an ICU level of care.

Choice D rationale

Cohabiting a client with active tuberculosis with another nonsurgical client is highly inappropriate and unsafe. Tuberculosis is transmitted via airborne particles, and co-rooming would expose the other client to a significant risk of infection. Dedicated isolation is paramount for preventing nosocomial spread.