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

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. 30 degrees:

This angle does not meet the criteria for a High Fowler's position, which requires a more upright position.

B. 15 to 20 degrees:

This angle is lower than what is generally considered as High Fowler's position. High Fowler's is a more upright position.

C. 90 degrees:

High Fowler's position involves elevating the head of the bed to 90 degrees. This position is often used for better lung expansion and respiratory function.

D. 45-60 degrees:

While this range is higher than a semi-Fowler's position, it is not as upright as the 90-degree elevation in a High Fowler's position.

A. Report the injury to a nurse manager B. Wash the affected area with soap and water C. Report the needle stick to infection control department D. Scrub the area with hand sanitizer for a full 2 minutes

Correct Answer is B

Explanation

A. Report the injury to a nurse manager:

While reporting the incident is important, the immediate action to take is cleaning the affected area to minimize the risk of infection.

B. Wash the affected area with soap and water:

This is the immediate priority to reduce the risk of potential infection or transmission of any contaminants from the needlestick injury.

C. Report the needle stick to the infection control department:

Reporting the incident is essential, but it should follow the immediate step of cleaning the affected area to prevent infection.

D. Scrub the area with hand sanitizer for a full 2 minutes:

Hand sanitizer may not be as effective as soap and water in removing contaminants from a needlestick injury site. Washing with soap and water is more appropriate for cleaning the area.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician’s admitting orders indicate that the client is to be placed in a High Fowler’s position. Upon positioning this client, how much will the nurse elevate the head of the bed?

Correct Answer is C

Explanation

A nurse is administering enoxaparin 40mg subcutaneous to a client for prevention of blood clots when the client suddenly moves causing the needle to exit the client’s tissue and stick the nurse’s finger. What is the nurse’s first priority action?

Correct Answer is B

Explanation

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following is the best action to transfer the client, for the first time, safely into the chair?

The nurse understands that sequential compression devices and compression stockings are used for which of the following?

The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

Various sounds are heard when assessing a blood pressure. What does the second sound heard through the stethoscope represent?

The nurse is taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?

A nurse is providing oral care to a client with dentures. What action would the nurse do first?

A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?