A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Measure abdominal girth twice weekly.

Monitor for the presence of WBCs in the urine.

Apply pressure to needlestick sites for 10 min.

Assess core temperatures using a rectal thermometer.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Measuring abdominal girth is not directly related to thrombocytopenia management.
B. Monitoring for WBCs in the urine is not related to thrombocytopenia.
C. Applying pressure to needlestick sites for 10 minutes helps prevent bleeding, which is crucial for clients with thrombocytopenia.
D. Using a rectal thermometer can increase the risk of bleeding and should be avoided in clients with thrombocytopenia.

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Correct Answer is ["B","D","E"]

Explanation

A. Allergies
Allergies are important to know but are not part of the primary survey. The primary survey focuses on immediate life threats, such as airway, breathing, and circulation, rather than detailed background information.
B. Circulation
Assessment of circulation is critical in the primary survey to identify and manage life-threatening conditions such as shock or severe bleeding. It includes evaluating blood pressure, heart rate, and peripheral pulses to assess the effectiveness of the cardiovascular system.
C. Neurological status
While neurological status is important, it is part of a secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions, while the neurological status is assessed more thoroughly in the secondary survey.
D. Ventilation
Assessing ventilation is a crucial part of the primary survey. This involves checking the client's breathing rate, depth, and effectiveness to ensure adequate oxygenation and addressing any immediate respiratory distress.
E. Current medications
Knowing current medications is important for overall care but is not part of the primary survey. The primary survey addresses life-threatening conditions rather than details of medication history.
F. Exposure
Exposure is part of the primary survey, ensuring that the client is completely exposed for a thorough assessment while protecting their privacy and warmth. It involves checking for hidden injuries and ensuring the client’s environment is safe.

A. Sleep on a soft mattress. B. Avoid prolonged sitting. C. Apply heat for 10 min every hour. D. Sleep in a side-lying position with flexed knees. E. Try padded shoe insoles.

Correct Answer is ["B","D","E"]

Explanation

Rationale:
A. Sleeping on a firm mattress is generally recommended to support the spine and prevent back strain.
B. Avoiding prolonged sitting helps reduce pressure on the lower back and can prevent back pain.
C. Applying heat intermittently can provide temporary relief but does not prevent back strain.
D. Sleeping in a side-lying position with knees flexed helps maintain natural spinal curvature and reduces strain on the back.
E. Padded shoe insoles may provide comfort. Proper arch support can improve posture and reduce stress on the lower back.

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A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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