(Select all that apply): A nurse is assessing a patient with thrombocytopenia.
Which interventions are appropriate for this patient? Select all that apply.
Administer platelet transfusion.
Encourage high-intensity physical activity.
Monitor for signs of bleeding.
Administer heparin therapy.
Educate the patient on infection prevention.
Correct Answer : A,C,E
Choice A rationale:
"Administer platelet transfusion." Rationale: This is an appropriate intervention for a patient with thrombocytopenia, especially if they are experiencing severe bleeding or have a very low platelet count.
Platelet transfusion can help increase the platelet count and prevent or stop bleeding.
Choice B rationale:
"Encourage high-intensity physical activity." Rationale: This intervention is not appropriate for a patient with thrombocytopenia.
High-intensity physical activity can increase the risk of bleeding in these patients due to the low platelet count.
Choice C rationale:
"Monitor for signs of bleeding." Rationale: This is an essential intervention for a patient with thrombocytopenia.
Monitoring for signs of bleeding, such as petechiae, ecchymosis, or mucosal bleeding, allows for early detection and intervention.
Choice D rationale:
"Administer heparin therapy." Rationale: This intervention is not appropriate for a patient with thrombocytopenia, especially if the thrombocytopenia is immune-mediated, as heparin can exacerbate the condition.
Choice E rationale:
"Educate the patient on infection prevention." Rationale: This is an appropriate intervention for a patient with thrombocytopenia.
Patients with low platelet counts are at increased risk of infection, so education on infection prevention measures, such as hand hygiene and avoiding sick individuals, is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
"Increased platelet production due to chemotherapy." Rationale: This statement is not accurate.
Chemotherapy often suppresses bone marrow function, leading to a decrease in platelet production, not an increase.
Thrombocytopenia is a common side effect of chemotherapy due to reduced platelet production.
Choice B rationale:
"Immune-mediated platelet destruction caused by chemotherapy." Rationale: This statement is correct.
Thrombocytopenia in patients undergoing chemotherapy is often due to immune-mediated platelet destruction.
Chemotherapy can trigger an autoimmune response, leading to the destruction of platelets by the immune system.
Choice C rationale:
"Thrombocytopenia in this case is unrelated to chemotherapy." Rationale: This statement is unlikely to be true.
Thrombocytopenia occurring in a patient following chemotherapy is often directly related to the treatment.
While other factors may contribute, chemotherapy is a known cause of decreased platelet counts.
Choice D rationale:
"Thrombocytopenia results from the inhibition of platelet aggregation by chemotherapy." Rationale: This statement is not accurate.
Chemotherapy primarily affects platelet production and can lead to a decrease in platelet count.
It does not typically inhibit platelet aggregation.
Correct Answer is D
Explanation
Choice A rationale:
Administering alternative anticoagulants.
Administering alternative anticoagulants is not the primary intervention for preventing or managing bleeding in a client with thrombocytopenia.
Anticoagulants may increase the risk of bleeding in such patients and are generally not indicated unless there is a specific medical reason to use them.
Choice B rationale:
Preparing the client for splenectomy.
Splenectomy is not typically performed as a preventive measure for bleeding in thrombocytopenic patients.
While splenectomy may be considered in some cases of immune thrombocytopenia, it is not the essential nursing intervention to prevent or manage bleeding in most clients with thrombocytopenia.
Choice C rationale:
Avoiding platelet transfusions.
Avoiding platelet transfusions is not a recommended intervention in clients with thrombocytopenia who are at risk of bleeding complications.
Platelet transfusions are often necessary to raise platelet levels and prevent or manage bleeding in these individuals.
Choice D rationale:
Applying pressure to any bleeding site and elevating the affected area.
This is the essential nursing intervention to prevent and manage bleeding in clients with thrombocytopenia.
Applying pressure to a bleeding site helps control bleeding, and elevating the affected area can reduce swelling and minimize bleeding.
It is a fundamental measure in the care of thrombocytopenic clients.
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