(Select all that apply):
A nurse is providing care to a patient with thrombocytopenia.
Which nursing interventions are appropriate for this patient? Select all that apply.
Administer platelet transfusions for life-threatening hemorrhage.
Discontinue heparin immediately if signs of thrombosis are present.
Teach the patient to avoid NSAIDs, aspirin, and alcohol.
Administer corticosteroids, IVIG, anti-D antibody, or rituximab as prescribed.
Monitor the patient's response to treatment by checking the skin color and temperature.
Correct Answer : B,C,D
Choice A rationale:
Administer platelet transfusions for life-threatening hemorrhage.
Platelet transfusions are typically administered in cases of severe thrombocytopenia where the risk of life-threatening hemorrhage is high.
However, it is not appropriate to administer platelet transfusions routinely or without a specific indication.
Therefore, this choice is not applicable in all cases of thrombocytopenia.
Choice B rationale:
Discontinue heparin immediately if signs of thrombosis are present.
In patients with thrombocytopenia, the use of heparin can increase the risk of bleeding.
If signs of thrombosis (clot formation) occur while a patient is on heparin, it is crucial to discontinue the medication promptly to prevent further clot formation.
This is a necessary intervention in such cases.
Choice C rationale:
Teach the patient to avoid NSAIDs, aspirin, and alcohol.
Patients with thrombocytopenia have a reduced number of platelets, which are essential for blood clotting.
NSAIDs (nonsteroidal anti-inflammatory drugs), aspirin, and alcohol can further increase the risk of bleeding by interfering with platelet function or causing irritation to the gastrointestinal tract.
Therefore, it is essential to educate patients to avoid these substances to minimize bleeding risks.
Choice D rationale:
Administer corticosteroids, IVIG, anti-D antibody, or rituximab as prescribed.
These treatments may be prescribed in specific cases of thrombocytopenia, depending on the underlying cause.
Corticosteroids can help reduce immune-mediated destruction of platelets, IVIG (intravenous immunoglobulin) can boost platelet levels, anti-D antibody is used in Rh-positive individuals with Rh-negative platelets, and rituximab may be prescribed for certain autoimmune causes of thrombocytopenia.
The administration of these medications is based on the patient's specific diagnosis and medical orders.
Choice E rationale:
Monitor the patient's response to treatment by checking the skin color and temperature.
While monitoring the patient's response to treatment is essential, checking skin color and temperature alone may not provide comprehensive information about thrombocytopenia management.
Monitoring platelet counts, signs of bleeding, and other relevant laboratory parameters would be more specific and valuable in assessing the effectiveness of treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
"Spontaneous bleeding in thrombocytopenia is due to excessive clotting." Rationale: This statement is not accurate.
Thrombocytopenia is characterized by a low platelet count, which impairs the blood's ability to form clots.
Spontaneous bleeding occurs because there are not enough platelets to participate in clot formation.
Choice B rationale:
"Immune-mediated destruction of platelets leads to spontaneous bleeding." Rationale: This is the correct answer.
In thrombocytopenia, especially immune thrombocytopenic purpura (ITP), the immune system destroys platelets, leading to a decreased platelet count.
This makes the patient more prone to spontaneous bleeding.
Choice C rationale:
"Bleeding occurs in thrombocytopenia due to increased platelet production." Rationale: This statement is incorrect.
Thrombocytopenia is characterized by a decreased platelet count, not increased production.
Choice D rationale:
"Thrombocytopenia-related bleeding is a result of heparin therapy." Rationale: This statement is inaccurate.
Thrombocytopenia related to heparin therapy is known as heparin-induced thrombocytopenia (HIT), and it occurs due to an immune response to heparin, not the same mechanism as in thrombocytopenia.
Correct Answer is B
Explanation
Choice A rationale:
"A normal platelet count is below 50,000/uL." Rationale: This statement is incorrect.
A platelet count below 50,000/uL is considered low and may indicate thrombocytopenia.
However, it is not within the normal range.
The normal platelet count range is higher.
Choice B rationale:
"The normal platelet count range is 150,000/uL to 400,000/uL." Rationale: This statement is accurate.
The normal platelet count range typically falls between 150,000/uL to 400,000/uL.
Platelets play a crucial role in blood clotting, and this range reflects the normal quantity needed for proper clot formation and prevention of excessive bleeding.
Choice C rationale:
"Platelet counts below 10,000/uL are considered normal." Rationale: This statement is incorrect.
A platelet count below 10,000/uL is extremely low and indicates severe thrombocytopenia.
It is not within the normal range.
Choice D rationale:
"A platelet count above 1,000,000/uL is typical in healthy individuals." Rationale: This statement is incorrect.
A platelet count above 1,000,000/uL is considered abnormally high and can lead to an increased risk of clot formation, which is not typical in healthy individuals.
The normal range is much lower.
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