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 D

Explanation

Choice A reason: This is an incorrect purpose, because raising the bed linens off the client's feet to prevent plantar flexion is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Raising the bed linens off the client's feet can be achieved by using a foot cradle or a bed frame.

Choice B reason: This is an incorrect purpose, because keeping the client's heels off the bed to prevent pressure ulcers is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Keeping the client's heels off the bed can be achieved by using a heel protector or a pillow under the lower legs.

Choice C reason: This is an incorrect purpose, because positioning the client off the operative site while in bed is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Positioning the client off the operative site can be achieved by using a trochanter roll or a pillow under the hip.

Choice D reason: This is the correct purpose, because preventing dislocation of the hip during position changes or movement is the main reason for using an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and

A. Have the client gently blow clots from his nose every 5 min B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the client’s neck D. Pinch the soft portion of the client’s nose for 10 min

Correct Answer is D

Explanation

Choice A reason: Having the client gently blow clots from his nose every 5 min is an incorrect action, because it can increase the bleeding and trauma to the nasal mucosa. The client should avoid blowing or picking his nose.

Choice B reason: Instructing the client to sit with his head hyperextended is an incorrect action, because it can cause the blood to drain into the throat and increase the risk of aspiration or vomiting. The client should sit with his head tilted forward.

Choice C reason: Applying ice compresses to the back of the client’s neck is an incorrect action, because it has no effect on the bleeding site. The nurse should apply ice compresses to the bridge of the nose or the cheeks to constrict the blood vessels and reduce the bleeding.

Choice D reason: Pinching the soft portion of the client’s nose for 10 min is a correct action, because it applies direct pressure to the bleeding site and allows clot formation. The nurse should instruct the client to breathe through his mouth and avoid swallowing the blood.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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