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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Implementing a recorded order message is not a standard practice and may not be permissible in all healthcare settings.
B. Transcribing the order into the client's health record is essential to ensure accurate documentation.
C. Repeating the order back to the provider ensures that the nurse has correctly understood the prescription.
D. Questioning any part of the order that is unclear or inappropriate ensures patient safety and accuracy.
E. While obtaining the provider's signature is necessary, the timeframe may vary depending on facility policies and regulations. The focus should be on ensuring the accuracy and clarity of the order first.
Correct Answer is C
Explanation
A. Pediculicide lotions are used to treat lice, not ticks. They are not effective or appropriate for tick removal.
B. Twisting a tick during removal can cause the mouthparts to break off and remain embedded in the skin, increasing the risk of infection.
C. Grasping the tick as close to the skin as possible with fine-tipped tweezers allows for complete removal without squeezing the tick's body.
D. Using a hot ember or match tip can cause the tick to regurgitate into the skin, increasing the risk of disease transmission.
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