A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

Wears a face mask around others

Increased intake of green, leafy vegetables

Uses a firm-bristled toothbrush

Sleeps 8 to 10 hr per night

Answer and Explanation

The Correct Answer is C

A. Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.

B. Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.

C. Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.

D. Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.

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Correct Answer is B

Explanation

Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.

"You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.

"You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.

"You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, it may not be the most effective strategy for managing pain when changing positions post-cesarean.

A. Dark red urine B. Frequent urge to urinate C. Urine output of 300 mL over 8 hr D. Occasional small clots in the urine

Correct Answer is A

Explanation

Dark red urine following a transurethral resection of the prostate (TURP) can indicate active bleeding or hematoma formation. It is important to notify the provider because further assessment and intervention may be necessary to address the source of the bleeding and prevent complications.

Frequent urge to urinate is expected after a TURP procedure as the bladder recovers and adapts to the changes. This is not a concerning finding and does not require immediate reporting to the provider.

Urine output of 300 mL over 8 hours can be considered adequate, especially in the early postoperative period. The nurse should continue to monitor the client's urinary output, but this finding does not require immediate reporting.

Occasional small clots in the urine can be expected after a TURP procedure due to the healing process and sloughing of tissue. However, if the clots become large or obstructive, or if there is a sudden increase in the frequency of clots, it should be reported to the provider.

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A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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