The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient?

Maintenance of reverse isolation

Administration of packed red blood cells

Administration of corticosteroids

Administration of clotting factors

Answer and Explanation

The Correct Answer is C

A. Maintenance of reverse isolation: Reverse isolation is used to protect immunocompromised patients from infection, not to prevent bleeding. While infection control is important, it does not directly address the primary pathophysiology of ITP, which is immune-mediated platelet destruction.

B. Administration of packed red blood cells: Packed red blood cells are given to treat anemia, which may develop from significant bleeding, but this is a supportive measure rather than the primary treatment. It does not address the underlying immune-mediated platelet destruction.

C. Administration of corticosteroids: Corticosteroids are first-line therapy for ITP because they suppress the immune system, reducing antibody-mediated platelet destruction. Early administration helps increase platelet count and reduce the risk of bleeding, directly targeting the pathophysiology of the disorder.

D. Administration of clotting factors: ITP is characterized by low platelet count, not deficiencies in clotting factors. Administering clotting factors does not correct the primary problem of immune-mediated platelet destruction and is not indicated in standard ITP management.

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Correct Answer is A

Explanation

A. Glomerular filtration rate (GFR): GFR is the most direct indicator of overall kidney function because it reflects the rate at which the kidneys filter blood and clear waste products. In acute kidney injury, improvement is best demonstrated by a rising GFR toward baseline values, indicating recovery of nephron function and improved filtration capacity.

B. Potassium level: Serum potassium levels are important to monitor because hyperkalemia is a life-threatening complication of AKI. However, potassium can fluctuate due to medications, diet, or temporary shifts between intracellular and extracellular compartments, making it less specific for evaluating true renal recovery.

C. Blood urea nitrogen (BUN) level: BUN is commonly elevated in AKI due to reduced excretion of nitrogenous waste. However, BUN can also be influenced by hydration status, protein intake, and catabolic states, limiting its reliability as a sole marker of improving kidney function.

D. Urine volume: Increased urine output may suggest improvement, particularly during the recovery phase of AKI. However, urine volume alone does not necessarily reflect adequate filtration, as patients may produce urine without effectively clearing solutes. Filtration capacity is more accurately assessed by GFR.

A. Apply dressings to burned areas B. Assess for pain at contact points C. Place on a cardiac monitor D. Start two large bore IVS

Correct Answer is C

Explanation

A. Apply dressings to burned areas: Wound care is important to reduce infection risk and protect damaged tissue, but in electrical burns, internal injuries may be more severe than external findings. Covering the wounds does not address immediate life-threatening complications such as cardiac dysrhythmias.

B. Assess for pain at contact points: Pain assessment is a routine component of burn care; however, electrical injuries may cause deep tissue damage with minimal external pain initially. Life-threatening cardiac complications take precedence over pain evaluation in the primary survey.

C. Place on a cardiac monitor: Electrical burns can disrupt myocardial conduction pathways, predisposing the patient to lethal dysrhythmias such as ventricular fibrillation. Continuous cardiac monitoring allows early detection and rapid intervention for arrhythmias, which are a leading cause of mortality in electrical injuries. Immediate monitoring is critical upon arrival.

D. Start two large bore IVs: Establishing large-bore IV access is essential for fluid resuscitation and medication administration. However, dysrhythmias can occur immediately after electrical exposure, making cardiac monitoring the first priority to detect and treat potentially fatal conduction abnormalities.

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The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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