A nurse is contributing to the plan of care for a client who has thrombocytopenia due to chemotherapy. Which of the following interventions should the nurse include?
Avoid IM injections.
Obtain a rectal temperature once per shift.
Do not allow the client to have visitors.
Encourage daily flossing between teeth.
The Correct Answer is A
Choice A reason: This is the correct intervention, because avoiding IM injections can prevent bleeding and hematoma formation in the client who has low platelet count and impaired clotting.
Choice B reason: This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.
Choice C reason: This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.
Choice D reason: This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Option Ais correct. NSAIDs like ibuprofen arecommonly prescribedfor SLE-related joint pain and inflammation, provided there are no contraindications (e.g., renal impairment). The client’s statement reflects appropriate understanding of symptom management.
Choice B reason: This is an incorrect statement, because SLE is a systemic autoimmune disease that can affect multiple organs and tissues, not just the skin. The client may experience symptoms such as rash, arthritis, nephritis, anemia, or pericarditis.
Choice C reason:Option Cis incorrect. SLE patients requirerigorous sun protection(SPF ≥30) to prevent UV-induced flares. SPF 15 is insufficient, indicating inadequate teaching.
Choice D reason: This is an incorrect statement, because a mild fever can indicate an infection or a flare-up of SLE, which can require medical intervention. The client should monitor the temperature and report any fever or signs of infection to the provider.
Correct Answer is A
Explanation
Choice A reason: This is the best intervention, because offering the client a bedpan every 2 hr can help prevent urinary retention, bladder distension, and infection, which can worsen the incontinence. It can also help maintain the client's dignity and comfort, and promote bladder retraining.
Choice B reason: This is an incorrect intervention, because limiting the client's daily fluid intake can cause dehydration, constipation, and urinary tract infection, which can aggravate the incontinence. The client should drink adequate fluids, unless the provider instructs otherwise.
Choice C reason: This is an incorrect intervention, because requesting a prescription for an indwelling urinary catheter is not recommended for a client who has occasional urinary incontinence. An indwelling urinary catheter can increase the risk of infection, trauma, and obstruction, and interfere with the bladder function. The nurse should use other methods of bladder management, such as intermittent catheterization, external catheter, or incontinence pads.
Choice D reason: This is an incorrect intervention, because ambulating the client to the bathroom every 30 min can be unrealistic, exhausting, and unsafe for a client who has hemiplegia, or paralysis of one side of the body, due to a stroke. The client may not be able to walk or transfer without assistance, and may fall or injure themselves. The nurse should assess the client's mobility and ability to use the bathroom, and provide appropriate aids and support.
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