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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased, strong:
A pulse amplitude of +3 indicates an increased or strong pulse. This suggests a forceful and palpable pulse, potentially associated with conditions like fever, anemia, or increased cardiac output.
B. Diminished, weaker than expected:
This would typically be associated with a lower than normal pulse amplitude. It might suggest poor peripheral perfusion or decreased cardiac output.
C. Absent, unable to palpate:
If the pulse is absent or unable to be palpated, it could indicate severe conditions such as vascular occlusion or cardiac arrest.
D. Bounding:
A bounding pulse is one with a forceful and strong amplitude. It suggests a powerful expansion of the arterial wall, and it can be associated with conditions like fever, anemia, or increased cardiac output.
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.
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