A nurse is caring for a patient diagnosed with thrombocytopenia. Which of the following interventions should the nurse prioritize to ensure the safety of the patient?

Encourage the patient to engage in strenuous exercise to improve circulation

Instruct the patient to use an electric razor for shaving

Teach the patient to use a water pick for oral hygiene

Request an order for subcutaneous heparin to prevent blood clots

Answer and Explanation

The Correct Answer is B

Choice A reason: Encouraging the patient to engage in strenuous exercise to improve circulation is not appropriate for someone with thrombocytopenia. Strenuous exercise can increase the risk of injury and bleeding, which is particularly dangerous for patients with a low platelet count.

Choice B reason: Instructing the patient to use an electric razor for shaving is the most appropriate intervention. Thrombocytopenia increases the risk of bleeding, and using an electric razor instead of a traditional blade helps minimize the risk of cuts and subsequent bleeding.

Choice C reason: Teaching the patient to use a water pick for oral hygiene is not recommended for thrombocytopenia patients. Water picks can cause bleeding of the gums, which is a concern for individuals with low platelet counts. Using a soft-bristled toothbrush is safer.

Choice D reason: Requesting an order for subcutaneous heparin to prevent blood clots is not advisable for a thrombocytopenia patient without specific medical indication. Heparin is an anticoagulant, and administering it to someone with low platelets can exacerbate the risk of bleeding.

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Correct Answer is ["A","D","F"]

Explanation

Choice A reason: An oxygen mask is essential for providing supplemental oxygen to the patient, especially if they experience respiratory distress or decreased oxygen saturation following a seizure. Ensuring adequate oxygenation is a priority in post-seizure care.

Choice B reason: A nasogastric tube may be used in specific situations for feeding or medication administration, but it is not routinely necessary for all patients treated for status epilepticus.

Choice C reason: A urinary catheter is used for managing urinary output, particularly in patients with retention or incontinence issues, but it is not immediately required for all patients post-status epilepticus.

Choice D reason: Suction set-up is necessary for maintaining the patient's airway and preventing aspiration, particularly if the patient has excessive secretions or vomits after a seizure. Suction equipment allows the nurse to quickly clear the airway and ensure the patient can breathe effectively.

Choice E reason: Tongue blades are not recommended for seizure management as they can cause injury. Historically, there was a misconception about using tongue blades to prevent tongue biting during seizures, but this practice is now discouraged due to the risk of oral injury.

Choice F reason: Side rail pads are important for protecting the patient from injury during potential future seizures. Padded side rails help prevent trauma from hitting the bed rails during convulsions and provide a safer environment for the patient.

A. Place the patient in restraints for safety B. Insert an NGT C. Anticipate thrombolytic therapy for ischemic stroke D. Establish IV access with normal saline E. Place the patient in the prone position

Correct Answer is ["C","D"]

Explanation

Choice A reason: Placing the patient in restraints for safety is not typically necessary unless the patient is agitated or a danger to themselves or others. This action is not directly addressing the acute condition of a stroke.

Choice B reason: Inserting an NGT (nasogastric tube) is not an immediate priority in the acute management of a stroke. This might be considered later if the patient has swallowing difficulties and needs nutritional support, but it is not a first-line intervention.

Choice C reason: Anticipating thrombolytic therapy for ischemic stroke is appropriate, as timely administration of thrombolytics can dissolve the clot and improve blood flow to the affected brain area, potentially reducing the severity of the stroke.

Choice D reason: Establishing IV access with normal saline is crucial for administering medications and maintaining hydration. It ensures that the patient can receive necessary interventions promptly.

Choice E reason: Placing the patient in the prone position is not appropriate in the management of an acute stroke. The prone position is generally used in respiratory conditions to improve oxygenation but is not relevant to stroke management.

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A nurse is caring for a patient diagnosed with thrombocytopenia. Which of the following interventions should the nurse prioritize to ensure the safety of the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply)

Correct Answer is ["A","D","F"]

Explanation

Correct Answer is ["C","D"]

Explanation

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