A nurse is caring for a patient who has a low platelet count and is at risk for bleeding. Which of the following is a critical factor or priority that the nurse should apply when considering how to obtain the patient’s vital signs?
Do not let the patient know you are counting their respirations
Let the patient rest for 5 minutes before you measure their blood pressure
Do not measure the patient’s temperature rectally
Count the patient’s radial pulse for 30 seconds and multiply it by 2
The Correct Answer is C
A. Do not let the patient know you are counting their respirations:
This is not directly related to obtaining vital signs and is not a critical factor for a patient with a low platelet count.
B. Let the patient rest for 5 minutes before you measure their blood pressure:
Allowing the patient to rest for a few minutes before measuring blood pressure is a good practice but may not be as critical as other considerations in a patient with a low platelet count.
C. Do not measure the patient’s temperature rectally:
Patients with low platelet counts are at an increased risk of bleeding. Rectal temperatures can be invasive and carry a risk of mucosal injury, making them less advisable in patients with bleeding risks.
D. Count the patient’s radial pulse for 30 seconds and multiply it by 2:
Counting the radial pulse is a suitable method for assessing heart rate in a patient at risk for bleeding. However, rectal temperature measurement should be avoided due to the risk of mucosal injury.
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Related Questions
Correct Answer is D
Explanation
A. Wash the client’s face:
While washing the client's face might be part of general care, when specifically providing oral care for a client with dentures, the first step should be to don gloves to ensure infection control and safety.
B. Remove dentures:
Removing dentures may be a step in the oral care process, but it should come after donning gloves to maintain proper infection control measures.
C. Apply lubricant:
Applying lubricant might be necessary, especially if the client experiences dryness or discomfort, but it should follow the step of donning gloves.
D. Don gloves:
This is the first action because it is crucial to wear gloves before handling a client's dentures or engaging in any oral care procedures. Gloves protect both the nurse and the client from potential infections and ensure proper hygiene during care.
Correct Answer is A
Explanation
A. 74-year-old female with malnutrition and a foley catheter in place:
Malnutrition can weaken the immune system, making the individual more susceptible to infections. Additionally, the presence of a foley catheter increases the risk of urinary tract infections.
B. 54-year-old female admitted for chest pain observation:
Chest pain observation does not inherently increase the risk of infection.
C. 34-year-old male admitted for seizure observation:
Seizure observation does not inherently increase the risk of infection.
D. 78-year-old male with right-sided hemiplegia following a stroke:
While the hemiplegia following a stroke may pose mobility challenges, the presence of malnutrition and a foley catheter in option A puts the patient at a higher risk for infection.
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