A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements indicates an understanding of the teaching?

"I will use an enema to manage my constipation."

"I will remove my shoes when I'm inside my house."

"I will wipe my nose instead of blowing it."

"I will floss between my teeth every time I brush."

Answer and Explanation

The Correct Answer is C

A) "I will use an enema to manage my constipation.": This statement is concerning because enemas can cause trauma to the rectal mucosa, which may lead to bleeding in a client with thrombocytopenia. Therefore, this action is not advisable and indicates a lack of understanding of safe practices.

B) "I will remove my shoes when I'm inside my house.": While removing shoes can help maintain cleanliness, it does not directly relate to managing thrombocytopenia or preventing bleeding. This statement does not reflect an understanding of the specific precautions needed for a client with low platelet counts.

C) "I will wipe my nose instead of blowing it.": This statement demonstrates an understanding of the need to minimize trauma to the nasal passages. Blowing the nose can increase the risk of bleeding in individuals with thrombocytopenia, so wiping is a safer alternative.

D) "I will floss between my teeth every time I brush.": Flossing can be harmful for a person with thrombocytopenia, as it may cause gum bleeding. Clients are often advised to avoid flossing to reduce the risk of bleeding, indicating that this statement reflects a misunderstanding of appropriate oral care practices for their condition.

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Correct Answer is B

Explanation

A) Flattening of the artificial airway cuff: This may indicate issues with the cuff pressure or an air leak but does not directly reflect the effectiveness of suctioning.

B) Decreased peak inspiratory pressure: This is the correct answer. A decrease in peak inspiratory pressure suggests that the airway is clearer, allowing for better airflow and indicating that the suctioning was effective in removing secretions that may have caused airway obstruction.

C) Presence of a productive cough: While this can indicate the expulsion of secretions, it may not be a reliable measure of the effectiveness of suctioning in a mechanically ventilated patient, as they may not be able to cough effectively.

D) Thinning of mucous secretions: While thinning secretions can be beneficial, it does not directly indicate that the suctioning itself was effective. The focus should be on airflow and pressure changes.

A. Perform the procedure prior to meals. B. Perform the procedure twice each day. C. Administer a bronchodilator after the procedure. D. Hold hand flat to perform percussions on the child.

Correct Answer is A

Explanation

A) Perform the procedure prior to meals: This is the correct action. Postural drainage should ideally be performed before meals to minimize the risk of vomiting and to ensure the child is comfortable during and after the procedure.

B) Perform the procedure twice each day: While frequency may vary based on the child's needs, it is often recommended to perform postural drainage more frequently than twice a day, depending on the severity of the condition and the child's specific respiratory needs.

C) Administer a bronchodilator after the procedure: Bronchodilators are typically administered before postural drainage to help open the airways and improve the effectiveness of the drainage. Giving them after the procedure is not standard practice.

D) Hold hand flat to perform percussions on the child: The correct technique for performing chest percussion is to cup the hand slightly, creating a pocket of air that helps to effectively dislodge mucus. A flat hand can be less effective and may not provide the necessary impact.

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A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements indicates an understanding of the teaching?

Nursing Test Bank

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