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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Related Questions
Correct Answer is B
Explanation
A. Coughing while swallowing food can help clear the airway but is not a primary technique for managing dysphagia.
B. Tilting the head forward when swallowing helps to close the airway and reduce the risk of aspiration, indicating effective teaching.
C. Food should be placed on the stronger side of the mouth to aid in effective chewing and swallowing.
D. A 30° angle is insufficient; the client should be in an upright position (90°) to reduce the risk of aspiration.
Correct Answer is C
Explanation
A. Fidelity refers to faithfulness and keeping promises made to clients.
B. Autonomy respects a client's right to make their own decisions about their care.
C. Nonmaleficence is a core principle in healthcare ethics and emphasizes the primary duty of healthcare providers to do no harm to their clients. This means carefully considering the potential risks and benefits of any treatment or intervention before administering it.
D. Justice ensures fair and equitable access to care for all individuals.
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