A nurse is caring for a client who has thrombocytopenia due to chemotherapy treatment. Which of the following actions should the nurse take?

Instruct the client to use a soft-bristled toothbrush

Administer a rectal suppository

Provide a low-residue diet

Encourage the client to use a safety razor when shaving

Answer and Explanation

The Correct Answer is A

Choice A reason: Thrombocytopenia from chemotherapy reduces platelets, impairing clotting and increasing bleeding risk. A soft-bristled toothbrush minimizes gum trauma, preventing hemorrhage in oral tissues, a common bleeding site. This instruction protects the client from excessive blood loss, aligns with bleeding precautions, and promotes safety during daily hygiene. It’s a practical, evidence-based measure to reduce mucosal injury, critical in managing low platelet counts effectively.

Choice B reason: Administering a rectal suppository risks rectal mucosal tearing in thrombocytopenia, where low platelets hinder clot formation, potentially causing significant bleeding. Chemotherapy-induced bone marrow suppression heightens this danger, making invasive procedures contraindicated. Safer alternatives, like oral medications, avoid this hazard. This action contradicts standard care, increasing harm in a client already prone to hemorrhage.

Choice C reason: A low-residue diet reduces bowel bulk, easing digestion, but doesn’t address thrombocytopenia’s bleeding risk, the primary concern here. It’s used in conditions like diverticulitis, not for platelet issues. Chemotherapy-related bleeding stems from vessel integrity, not diet, so this action lacks relevance. It fails to mitigate the client’s key vulnerability, making it inappropriate.

Choice D reason: Encouraging a safety razor in thrombocytopenia heightens bleeding risk, as even minor skin nicks won’t clot properly with low platelets from chemotherapy. Electric razors are recommended instead, minimizing cuts. This advice endangers the client, opposing bleeding precautions critical for safety. It ignores the condition’s pathophysiology, where external trauma must be avoided to prevent uncontrolled bleeding.

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Correct Answer is C

Explanation

Choice A reason: Infusing 0.9% sodium chloride at 150 mL/hr through an arterial line is excessive and dangerous, risking fluid overload or vessel damage. Arterial lines use a slow flush (1-3 mL/hr) to maintain patency, not high-volume infusion. This rate suits IV hydration, not arterial monitoring, making it an incorrect and harmful action for this setup.

Choice B reason: Having the client bear down (Valsalva maneuver) increases intrathoracic pressure, falsely elevating arterial readings, distorting accuracy. Arterial lines provide continuous, real-time pressure via transducers, not manual checks requiring such actions. This technique applies to venous lines or respiratory tests, not arterial monitoring, rendering it inappropriate and misleading here.

Choice C reason: Maintaining the pressure bag at 300 mm Hg ensures a continuous flush (1-3 mL/hr) of saline, preventing clot formation in the arterial line, which could block it. This pressure exceeds arterial systolic values, keeping the system patent and readings accurate. It’s a standard practice, critical for reliable monitoring, making it the correct action in this scenario.

Choice D reason: Aligning the transducer to the radial artery level is incorrect; it should be at the phlebostatic axis (heart level) for accurate pressure readings. Radial alignment overestimates pressure due to gravitational effects, skewing data. Proper calibration at the heart ensures true arterial values, so this action fails to meet monitoring standards.

A. Perform the reconciliation only at admission and discharge B. Compare only the prescribed home medications to the new prescriptions C. Delete new prescriptions that may interact with home medications D. Consider the risk for medication interactions

Correct Answer is D

Explanation

Choice A reason: Limiting reconciliation to admission and discharge misses medication changes during hospitalization, risking errors or omissions. Effective reconciliation occurs at all care transitions—admission, transfers, discharge—ensuring a current, accurate list. This approach prevents discrepancies, like duplicative therapies or missed doses, that could harm the client. Skipping interim updates undermines safety, as hospital regimens evolve, making this action incomplete and inadequate for proper care.

Choice B reason: Comparing only home medications to new prescriptions excludes drugs given during hospitalization, creating an incomplete profile. Reconciliation requires reviewing all medications—home, inpatient, and discharge—to identify conflicts or redundancies. Focusing solely on prescribed home meds overlooks real-time additions, like painkillers or antibiotics, risking interactions or therapeutic gaps. This narrow scope fails to meet reconciliation’s comprehensive safety goal.

Choice C reason: Deleting new prescriptions with potential home medication interactions exceeds nursing scope and risks altering treatment without provider input. Reconciliation identifies conflicts for collaborative resolution, not unilateral changes. For example, removing a necessary anticoagulant due to an interaction could harm the client. This action bypasses clinical judgment, undermining the process’s intent to flag, not fix, issues independently.

Choice D reason: Considering medication interaction risks is the essence of reconciliation, ensuring safety by identifying conflicts between home and hospital drugs—like warfarin and antibiotics increasing bleeding risk. The nurse compiles a full list, assesses potential adverse effects, and reports to the provider for adjustments. This proactive step prevents harm, aligns with standards, and supports individualized care, making it the correct action.

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A nurse is caring for a client who has thrombocytopenia due to chemotherapy treatment. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

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