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(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.

Answer and Explanation

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.

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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.

A. Schistocytes suggest normal platelet function. B. Schistocytes are associated with thrombocytosis. C. Schistocytes indicate hemolysis or microangiopathy. D. Schistocytes confirm the absence of bleeding risk.

Correct Answer is C

Explanation

Choice A rationale:

Schistocytes suggest normal platelet function.

Rationale: This statement is incorrect.

Schistocytes are not related to platelet function.

Schistocytes are fragmented red blood cells, and their presence on a peripheral blood smear suggests mechanical damage to red blood cells, not platelets.

Choice B rationale:

Schistocytes are associated with thrombocytosis.

Rationale: This statement is incorrect.

Schistocytes are not associated with thrombocytosis, which is an elevated platelet count.

They are more commonly associated with conditions involving red blood cell fragmentation, such as hemolysis or microangiopathy.

Choice C rationale:

Schistocytes indicate hemolysis or microangiopathy.

Rationale: This statement is correct.

Schistocytes are fragmented red blood cells, and their presence on a peripheral blood smear is indicative of hemolysis (destruction of red blood cells) or microangiopathy (damage to small blood vessels)

This finding suggests that the patient may have an underlying condition leading to red blood cell destruction, which can be associated with thrombocytopenia.

Choice D rationale:

Schistocytes confirm the absence of bleeding risk.

Rationale: This statement is incorrect.

Schistocytes do not confirm the absence of bleeding risk.

While they are associated with conditions involving red blood cell damage, they do not provide information about the patient's platelet count, which is a more direct factor in bleeding risk.

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(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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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(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.