A nurse is reinforcing teaching with a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues.

Use a floss pick instead of the floss string to floss in between the teeth.

Apply an ice pack over a bleeding wound.

Only use a soft-bristle toothbrush.

Answer and Explanation

The Correct Answer is D

A. Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues: While wearing loose or visible clothing may allow skin issues to be seen, it does not directly prevent bleeding complications, and there are more effective measures to focus on.

B. Use a floss pick instead of the floss string to floss in between the teeth: Flossing in any form, especially using a floss pick, can still increase the risk of gum bleeding in thrombocytopenic clients. It is safer to avoid flossing altogether or consult a dentist.

C. Apply an ice pack over a bleeding wound: While applying an ice pack may reduce bleeding once it occurs, it does not prevent bleeding. The focus should be on avoiding activities that increase the risk of bleeding.

D. Only use a soft-bristle toothbrush: Using a soft-bristle toothbrush helps reduce the risk of bleeding from the gums, which is a common issue for clients with thrombocytopenia due to the reduced platelet count.

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Correct Answer is C

Explanation

A. Elevate the head of the bed to 90 degrees: While elevating the head of the bed may help ease breathing, it does not address the potential issue of NG tube misplacement.

B. Administer a bronchodilator as prescribed: This would only be appropriate if the patient’s respiratory distress were related to bronchospasm or asthma, not NG tube displacement.

C. Check the placement of the NG tube to ensure it has not dislodged into the lungs. When a patient with an NG tube experiences respiratory distress, the tube may have dislodged and entered the respiratory tract, which could obstruct breathing. Verifying the placement of the NG tube is critical to preventing aspiration or further complications.

D. Increase the flow rate of the patient’s oxygen therapy: This may provide temporary relief but does not resolve the underlying cause of the distress if the NG tube has entered the respiratory tract.

A. Costovertebral angle tenderness B. Suprapubic tenderness C. Abdominal distention D. Lower extremity edema

Correct Answer is B

Explanation

A. Costovertebral angle tenderness: Costovertebral angle tenderness is more indicative of pyelonephritis (kidney infection) rather than cystitis, as it signals an upper urinary tract infection.

B. Suprapubic tenderness: Suprapubic tenderness is a classic sign of cystitis. This symptom, combined with dysuria and increased urinary frequency, strongly supports the diagnosis.

C. Abdominal distention: Abdominal distention is not typically associated with cystitis. It may suggest other conditions like bowel obstruction or ascites.

D. Lower extremity edema: Lower extremity edema is not a common finding in cystitis. It is more associated with systemic conditions like heart failure or kidney disease.

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A nurse is reinforcing teaching with a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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A nurse is reinforcing teaching with a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?