A patient with newly diagnosed ITP is admitted with petechiae and ecchymoses. Which action should the nurse take first?

Prepare the patient for platelet transfusion.

Institute bleeding precautions.

Encourage active range-of-motion exercises.

Administer aspirin for discomfort.

Answer and Explanation

The Correct Answer is B

A. Prepare the patient for platelet transfusion: In immune thrombocytopenic purpura (ITP), platelet destruction is immune mediated, and transfused platelets are often rapidly destroyed unless there is severe or life-threatening bleeding. Platelet transfusion is not the first intervention for petechiae and ecchymoses without active hemorrhage. Immediate safety measures take priority.

B. Institute bleeding precautions: ITP results in decreased platelet counts due to autoimmune destruction, increasing the risk for spontaneous bleeding. Implementing bleeding precautions—such as avoiding IM injections, using soft toothbrushes, and minimizing invasive procedures—reduces the risk of mucosal or internal hemorrhage. Preventing further bleeding is the priority upon admission.

C. Encourage active range-of-motion exercises: Vigorous activity may increase the risk of bruising or internal bleeding in patients with thrombocytopenia. While mobility is important, activity should be limited or modified until platelet levels are stabilized. Preventing trauma is more urgent than promoting exercise at this stage.

D. Administer aspirin for discomfort: Aspirin inhibits platelet aggregation by irreversibly blocking cyclooxygenase-1 (COX-1), impairing thromboxane A2 production. In a patient with already reduced platelet numbers, aspirin significantly increases bleeding risk and is contraindicated.

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Correct Answer is A

Explanation

A. Glomerular filtration rate (GFR): GFR is the most direct indicator of overall kidney function because it reflects the rate at which the kidneys filter blood and clear waste products. In acute kidney injury, improvement is best demonstrated by a rising GFR toward baseline values, indicating recovery of nephron function and improved filtration capacity.

B. Potassium level: Serum potassium levels are important to monitor because hyperkalemia is a life-threatening complication of AKI. However, potassium can fluctuate due to medications, diet, or temporary shifts between intracellular and extracellular compartments, making it less specific for evaluating true renal recovery.

C. Blood urea nitrogen (BUN) level: BUN is commonly elevated in AKI due to reduced excretion of nitrogenous waste. However, BUN can also be influenced by hydration status, protein intake, and catabolic states, limiting its reliability as a sole marker of improving kidney function.

D. Urine volume: Increased urine output may suggest improvement, particularly during the recovery phase of AKI. However, urine volume alone does not necessarily reflect adequate filtration, as patients may produce urine without effectively clearing solutes. Filtration capacity is more accurately assessed by GFR.

A. Sluggish pupillary response to light B. Vomiting C. Headache D. Change in level of consciousness

Correct Answer is D

Explanation

A. Sluggish pupillary response to light: Changes in pupillary response typically occur as increased intracranial pressure (ICP) progresses and cranial nerve III becomes compressed. This is a later sign and may indicate significant neurologic compromise.

B. Vomiting: Vomiting can result from increased ICP due to stimulation of the vomiting center in the medulla. However, it is a nonspecific symptom and often occurs after early neurologic changes.

C. Headache: Headache is a common symptom of elevated ICP caused by stretching of pain-sensitive structures in the meninges. While it may appear early, it is subjective and can be difficult to assess, especially in patients with altered consciousness.

D. Change in level of consciousness: Alteration in level of consciousness, such as confusion, restlessness, or drowsiness, is the earliest and most sensitive indicator of rising ICP. It reflects the brain’s response to pressure before overt focal neurologic deficits or cranial nerve changes occur.

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A patient with newly diagnosed ITP is admitted with petechiae and ecchymoses. Which action should the nurse take first?

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