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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 A

Explanation

Choice B rationale:

Administer plasma exchange therapy Administering plasma exchange therapy may be indicated in some cases of thrombocytopenia, but it is not the initial intervention when a client presents with petechiae, pallor, and weakness.

The primary concern in this situation is addressing active bleeding, which is best managed by applying pressure to bleeding sites and elevating the affected area.

Choice C rationale:

Monitor renal function and fluid balance While monitoring renal function and fluid balance is important in the overall care of a client with thrombocytopenia, it is not the immediate intervention when the client presents with symptoms of bleeding and weakness.

The priority is to stop the bleeding by applying pressure and elevating the affected area.

Choice D rationale:

Prepare the client for immunosuppressant therapy Immunosuppressant therapy may be considered as a treatment option for certain types of thrombocytopenia, but it is not the initial intervention when the client has active bleeding and weakness.

The immediate focus should be on bleeding control and symptom management.

A. Administer platelet transfusion. B. Encourage high-intensity physical activity. C. Monitor for signs of bleeding. D. Administer heparin therapy. E. Educate the patient on infection prevention.

Correct Answer is ["A","C","E"]

Explanation

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.

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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

A client with thrombocytopenia presents with petechiae, pallor, and weakness.Which intervention should the nurse implement to address the client's symptoms?

Correct Answer is A

Explanation

(Select all that apply): A nurse is assessing a patient with thrombocytopenia.Which interventions are appropriate for this patient? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A client with thrombocytopenia is at risk of bleeding complications.Which nursing intervention is essential to prevent and manage bleeding in this client?

A nurse is educating a patient and their family about thrombocytopenia.Which statement accurately describes the normal platelet count range?

A client with thrombocytopenia presents with schistocytes on the peripheral blood smear.What does the presence of schistocytes indicate, and how should the nurse interpret this finding?

A client with thrombocytopenia experiences prolonged bleeding even after minor trauma.What statement by the nurse accurately explains the relationship between platelet count and bleeding risk?

A nurse is caring for a patient with thrombocytopenia.The patient presents with mucosal bleeding, including petechiae, purpura, and gingival bleeding.What should the nurse anticipate when assessing this patient's platelet count?

A client with thrombocytopenia is experiencing spontaneous bleeding.Which statement best explains the potential cause of this bleeding?

A nurse is conducting a physical examination of a patient suspected of having thrombocytopenia. What assessment findings should the nurse prioritize to identify potential causes and types of thrombocytopenia?

A client has developed thrombocytopenia following chemotherapy.What is the likely cause of thrombocytopenia in this patient?

(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.