The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-PA) on admission. The family member requests to bring in a razor for the client to use. Which response from the family would indicate an understanding teaching related to t-PA? The family member states, "I will

be careful with the straight razor."

insist the nurse use multiple razor blades."

bring in an electric razor for nurse to use for shaving."

bring in disposable razors blades to use for, shaving."

Answer and Explanation

The Correct Answer is C

A.   This response shows some awareness but does not indicate a sufficient understanding of the risks. Straight razors can pose a significant risk of cuts and bleeding, especially in a patient who has received t- PA, which can increase the likelihood of bleeding.
B.   This response suggests a misunderstanding. Using multiple razor blades does not inherently reduce the risk of bleeding and could increase the chance of cuts or nicks. This response does not indicate an appropriate understanding of safety precautions related to t-PA.
C.   This response indicates an understanding of safety precautions. Electric razors are safer for clients who are at risk of bleeding because they do not have sharp blades that can easily cause cuts. This choice minimizes the risk of injury while allowing for personal grooming.
D.   While disposable razors may seem convenient, they still carry a risk of cuts and bleeding. This response does not reflect a full understanding of the precautions necessary for a client who has received t-PA, as it does not prioritize safety in the same way that using an electric razor does.

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Correct Answer is ["B","C","D"]

Explanation

A. Bacitracin is an antibiotic ointment typically used to prevent or treat bacterial infections in minor cuts and scrapes. It is not appropriate for treating a pruritic rash associated with GVHD. The rash may not be due to an infection but rather an immune response, so using bacitracin would not address the underlying issue.
B. Diphenhydramine (Benadryl) and hydroxyzine are antihistamines that can help alleviate itching and provide relief from pruritus. Requesting a prescription for one of these medications is an appropriate response to manage the symptoms of GVHD.
C. Showering with cool water can soothe irritated skin and reduce itching. Using mild soap helps to avoid further irritation or dryness that harsher soaps can cause. This intervention supports skin care and helps manage pruritus effectively.
D. Clipping fingernails can help prevent skin damage from scratching, which could lead to secondary infections. Encouraging the use of prescribed lotions can help keep the skin moisturized and alleviate dryness, further addressing the pruritus associated with GVHD.

A. Complaints of pain at the incision B. Increased blood pressure C. Decreased white blood cell count D. Presence of blood on the pillow behind the patient

Correct Answer is D

Explanation

A. While pain can occur post-operatively and may be a sign of complications, it is not a direct indicator of bleeding. Pain can result from normal healing, surgical trauma, or other complications, but by itself, it does not specifically point to bleeding at the surgical site.
B. An increased blood pressure might not necessarily indicate bleeding. In some cases, blood pressure may increase due to pain, anxiety, or other factors. However, a significant drop in blood pressure would be more indicative of bleeding, especially in conjunction with other symptoms.
C. A decreased white blood cell count (leukopenia) is not typically associated with bleeding at the surgical site. In fact, following surgery, one might expect the white blood cell count to be normal or slightly elevated due to the body’s response to surgery.
D. This finding is indicative of bleeding at the surgical site. Blood on the pillow would suggest that there is active bleeding that has escaped from the surgical site, which is a significant concern that requires immediate assessment and intervention.

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Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male: 451-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-155 g/dL
Hematocrit	42%-52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 10/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%


Platelets	150,000-450,000/mm3

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Naxlex Comprehensive Predictor Exams

The client has developed graft versus host disease (GVHD) during treatment for acute lymphoblastic leukemia (ALL). The client has a generalized pruritic rash on the trunk and the extremities. What nursing measures should the nurse use to address this problem?

Correct Answer is ["B","C","D"]

Explanation

The nurse is assessing a post-op thyroidectomy patient for bleeding. Which finding would indicate bleeding at the surgical site?

Correct Answer is D

Explanation

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