A nurse is developing a care plan for a patient who has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which of the following symptoms is most important for the nurse to monitor?

Elevated WBC count.

Fever.

Ecchymosis.

Fatigue.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While an elevated WBC count can indicate an infection, it is not the most important symptom to monitor in a patient with idiopathic thrombocytopenic purpura (ITP). ITP is primarily a platelet disorder, and while infection can trigger or exacerbate the condition, an elevated WBC count is not a direct symptom of ITP78.

Choice B rationale

Fever can be a sign of infection, which can trigger or exacerbate ITP. However, it is not the most important symptom to monitor in a patient with ITP78.

Choice C rationale

Ecchymosis, or bruising, is a key symptom of ITP. Because ITP involves a decrease in platelets, which are necessary for clotting, patients with this condition are prone to bruising and bleeding. Therefore, monitoring for ecchymosis is crucial.

Choice D rationale

Fatigue can be a symptom of ITP, but it is not the most important symptom to monitor. While fatigue can impact a patient’s quality of life, it does not directly indicate the severity of the condition.

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Correct Answer is A

Explanation

Choice A rationale

Tremors are a common side effect of terbutaline. Terbutaline is a medication used to inhibit uterine contractions in preterm labor. It is a beta-adrenergic agonist, and stimulation of the beta-adrenergic receptors can lead to side effects such as tremors.

A. Have the patient void. B. Ask the patient if she needs pain medication. C. Turn the patient on her side and recheck the blood pressure. D. Notify the healthcare provider of the findings.

Correct Answer is C

Explanation

Choice A rationale

Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.

Choice B rationale

Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.

Choice C rationale

Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.

Choice D rationale

Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.

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A nurse is developing a care plan for a patient who has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which of the following symptoms is most important for the nurse to monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in premature labor and is receiving terbutaline.Which of the following adverse effects should the nurse monitor for and report to the provider?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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