A patient with idiopathic thrombocytopenic purpura (ITP) presents with heavy lochia and petechiae. As the nurse, which priority intervention would be most appropriate to prevent complications?
Monitor the patient's platelet count regularly.
Instruct the patient to take vitamin K supplements.
Administer platelet transfusions
Encourage the patient to engage in physical activity.
Administer a high dose of aspirin for pain relief.
The Correct Answer is C
Rationale:
A. Monitoring platelet levels is important for ongoing assessment, but it is not an immediate intervention to prevent bleeding complications. It informs treatment decisions but does not actively stop current bleeding.
B. Vitamin K is primarily used to support clotting factor synthesis in liver disease or vitamin K deficiency. In ITP, the problem is immune-mediated destruction of platelets, not a vitamin K deficiency, so supplementation will not prevent bleeding.
C. In patients with ITP who present with active bleeding, especially heavy lochia and petechiae, platelet transfusions are the priority intervention. They temporarily increase circulating platelet levels, helping to control bleeding and prevent serious complications such as hemorrhage. This intervention addresses the immediate risk to patient safety.
D. Physical activity can increase the risk of trauma and bleeding in patients with low platelet counts. During active bleeding, activity should be limited, not encouraged.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
Rationale:
A. Older adults (≥65 years) have decreased immune function and reduced respiratory muscle strength. In myasthenia gravis, weakened respiratory muscles further increase the risk of ineffective airway clearance and pneumonia.
B. Clients with asthma have compromised airway function, and clients with AIDS are immunocompromised. Both conditions significantly increase susceptibility to respiratory infections, including pneumonia, especially when combined with myasthenia gravis.
C. Vaccination against pneumococcus and influenza is protective, not a risk factor. It reduces the likelihood of developing pneumonia, making this option incorrect.
D. Local anesthesia does not significantly depress respiratory function or airway protective reflexes compared to general anesthesia. Therefore, it does not substantially increase pneumonia risk in this context.
E. Mechanical ventilation is a major risk factor for ventilator-associated pneumonia (VAP). Additionally, a closed head injury may impair cough and gag reflexes, increasing aspiration risk.
F. Dysphagia (difficulty swallowing) greatly increases the risk of aspiration, which can lead to aspiration pneumonia. This is especially significant in myasthenia gravis due to bulbar muscle weakness.
Correct Answer is A
Explanation
Rationale:
A. Levothyroxine is usually a lifelong therapy for primary hypothyroidism. Stopping the medication once thyroid hormone levels normalize can lead to a return of hypothyroid symptoms and potential complications such as fatigue, bradycardia, and weight gain. Patients must understand that normalization of lab values does not mean the underlying thyroid deficiency is cured.
B. Regular monitoring of TSH and free T4 is essential to ensure the dose is appropriate and to prevent over- or under-replacement. Lab checks are typically done 6–8 weeks after starting or adjusting therapy and periodically thereafter.
C. Consistent daily use is critical because missing doses can lead to fluctuating thyroid hormone levels and recurrence of hypothyroid symptoms.
D. Levothyroxine absorption is maximized on an empty stomach, typically 30–60 minutes before breakfast, and should be taken separately from medications or supplements (like calcium or iron) that can impair absorption.
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