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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determining what the client already knows about managing diabetes is the initial step in assessing the client's current knowledge and understanding. This helps the nurse tailor the teaching plan to the client's needs and avoid redundancy.
B. Providing access to a video about diabetes may be part of the teaching plan but should come after assessing the client's baseline knowledge.
C. Establishing short-term, realistic goals is important but should follow the assessment of the client's current knowledge and understanding.
D. Evaluating the effectiveness of the client's admission teaching plan is important but should occur after the initial assessment and implementation of a personalized teaching plan.
Correct Answer is C
Explanation
A. Labeling the feeding bag is important for ensuring the safety and monitoring of feeding times, but it is not the first action.
B. Hanging the feeding bag at the correct height ensures proper flow of the feeding but is not the first action.
C. Aspirating the client's stomach contents is the first action to check for residuals and ensure the placement of the NG tube is correct, preventing aspiration.
D. Warming the feeding to room temperature is important for client comfort but is not the first action.
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