The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?

Report fever to MD ASAP

Use soft toothbrush with oral care

Drink hot liquids TID

Recommend Straight edge razor for shaving

Answer and Explanation

The Correct Answer is B

A. Report fever to MD ASAP: While fever in any immunocompromised patient should be reported, it does not directly address precautions related to low platelet counts and bleeding risks.

B. Use a soft toothbrush with oral care: With a low platelet count, the patient is at risk for bleeding. Using a soft toothbrush minimizes the risk of gum injury and bleeding, a critical safety measure for thrombocytopenic patients.

C. Drink hot liquids TID: Hot liquids are not recommended as they may cause mouth or esophageal burns, increasing bleeding risk if the mucosa is damaged. Tepid or cold fluids are safer.

D. Recommend straight edge razor for shaving: Patients with low platelets should use an electric razor to avoid cuts, as any bleeding is harder to control in thrombocytopenic individuals.

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Correct Answer is B

Explanation

A. Initiate a 2 L/day fluid restriction: Hydration is crucial in sickle cell crisis to prevent further sickling and reduce blood viscosity. A fluid restriction would worsen the crisis.

B. Assist with administering a blood transfusion: Blood transfusions are commonly given during sickle cell crisis to manage anemia and reduce the concentration of sickled cells, which can improve oxygen delivery and relieve pain.

C. Withhold opioids to avoid dependence: Pain management, including opioids if needed, is essential during a sickle cell crisis. The risk of dependence is secondary to controlling acute pain.

D. Encourage exercise: Rest is recommended during a crisis to reduce oxygen demand and prevent further sickling. Exercise would increase oxygen needs, worsening the crisis.

A. Pulmonary congestion B. Urticaria C. Vomiting D. Low back pain

Correct Answer is D

Explanation

A. Pulmonary congestion: Pulmonary congestion is associated more with fluid overload or transfusion-associated circulatory overload (TACO), not an acute hemolytic reaction.

B. Urticaria: Urticaria (hives) is more typical of a mild allergic reaction rather than an acute hemolytic reaction.

C. Vomiting: Although nausea and vomiting may occur in various transfusion reactions, it is not specific to an acute hemolytic reaction like low back pain is.

D. Low back pain: Low back pain, often around the kidneys, is a classic sign of an acute hemolytic reaction due to the breakdown of RBCs and the release of hemoglobin into the bloodstream, which can lead to renal damage. This reaction is a medical emergency requiring immediate intervention.

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The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?

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