A nurse is caring for a client.

Exhibits

Based on the information in the EHR, which of the following actions should the nurse take? Select all that apply.

A. Fever. While fever can indicate an underlying infection or inflammatory process, it is not a hallmark feature of idiopathic thrombocytopenic purpura (ITP). ITP is primarily a disorder of platelet destruction rather than an infectious or febrile illness. However, if the patient develops a fever, it may warrant investigation for secondary infections, especially if immunosuppressive therapy (e.g., corticosteroids) is being used.
B. Fatigue. Fatigue can occur in ITP due to chronic bleeding leading to anemia, but it is not the most critical parameter to monitor. While some patients with ITP experience fatigue due to immune dysregulation or blood loss, it is a nonspecific symptom that does not directly guide clinical management.
C. Ecchymosis. This is the most appropriate manifestation to monitor, as ITP is characterized by thrombocytopenia, leading to an increased risk of spontaneous bleeding and bruising (ecchymosis). Patients often present with petechiae, purpura, or mucosal bleeding (e.g., epistaxis, gingival bleeding). Close monitoring for worsening bruising, prolonged bleeding, or signs of internal hemorrhage (e.g., hematuria, melena) is essential for managing ITP effectively and determining treatment response.
D. Elevated WBC. ITP is an autoimmune condition primarily affecting platelet levels and does not directly cause an elevated white blood cell (WBC) count. An increased WBC count may suggest an infection, inflammation, or hematologic malignancy, but it is not a characteristic feature of ITP. Monitoring platelet counts, bleeding tendencies, and potential adverse effects of immunosuppressive therapy is more clinically relevant.

A. Have the client refrain from talking for 24 hr. While the throat may be sore after a bronchoscopy, complete voice rest for 24 hours is not necessary. The client may speak as tolerated once their gag reflex returns.
B. Suction the client’s oropharynx frequently. Routine oropharyngeal suctioning is not recommended unless the client has excessive secretions or airway obstruction. Unnecessary suctioning can cause irritation and discomfort.
C. Irrigate the client’s throat every 4 hr. Throat irrigation is not a standard postbronchoscopy intervention. Instead, throat lozenges or gargling with warm saline may help if the client experiences mild throat discomfort.
D. Withhold food and liquids until the client’s gag reflex returns. This is the most appropriate nursing action. A bronchoscopy involves the use of local anesthesia to numb the throat, which temporarily suppresses the gag reflex. To prevent aspiration, food and fluids should be withheld until the gag reflex has fully returned.