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 ["C","D"]

Explanation

A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

36. A nurse is caring for a client. Exhibits Which of the following findings at 1015 requires further action?

Correct Answer is ["C","D"]

Explanation

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)

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

Explanation

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