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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: This is an incorrect instruction, because the client does not need to remain NPO, or nothing by mouth, before a standard EEG. The client can eat and drink normally, unless the provider instructs otherwise.

Choice B reason: This is an incorrect instruction, because the client should not take a sedative, or any other medication that can affect the brain activity, before a standard EEG. The client should take the usual medications, unless the provider instructs otherwise.

Choice C reason: This is the correct instruction, because the client should thoroughly shampoo hair prior to the EEG. The client should wash the hair with a mild shampoo and rinse well, without using any conditioner, gel, spray, or other hair products. This can help remove any oil, dirt, or residue that can interfere with the placement and function of the electrodes.

Choice D reason: This is an incorrect instruction, because the client should not take an additional dose of anticonvulsant medication before a standard EEG. The client should take the regular dose of anticonvulsant medication, unless the provider instructs otherwise.

A. Weigh the client before and after each dialysis treatment. B. Apply clean gloves when handling the bags of dialysate fluid. C. Refrigerate the bags of dialysate fluid until ready for instillation. D. Check peripheral circulation of the client's arms prior to treatment.

Correct Answer is A

Explanation

Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.

Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.

Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.

Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.

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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?

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Naxlex Comprehensive Predictor Exams

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