The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP) whose platelet count is 10,000/mm³. What assessment finding will the nurse report to the provider immediately?
The patient has scattered petechiae on bilateral lower extremities.
The patient has ecchymosis around their intravenous site.
The Correct Answer is B
Choice A reason: Scattered petechiae on bilateral lower extremities are a common finding in patients with thrombocytopenia, indicating low platelet count and increased risk of bleeding. While this finding is concerning, it is not as immediate a threat as significant bleeding or bruising.
Choice B reason: Ecchymosis around the intravenous site suggests significant bleeding and bruising, which can be more urgent and requires immediate reporting. A platelet count of 10,000/mm³ is critically low, increasing the risk of spontaneous bleeding and haemorrhage. Immediate intervention is necessary to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The ABG results of pH 7.21, PaCO2 36, HCO3 14 indicate metabolic acidosis, which is common in patients with end-stage kidney disease (ESKD). In ESKD, the kidneys lose their ability to excrete acid and maintain bicarbonate levels, leading to an accumulation of acid in the blood. This condition results in a low pH (acidic), normal PaCO2 (as the respiratory system attempts to compensate), and low HCO3 (bicarbonate).
Choice B reason: The ABG results of pH 7.50, PaCO2 29, HCO3 22 indicate respiratory alkalosis, which is not typically associated with ESKD. Respiratory alkalosis occurs when there is excessive exhalation of carbon dioxide, leading to a higher pH (alkaline). This condition is more likely to be seen in situations such as hyperventilation, anxiety, or certain lung diseases.
Choice C reason: The ABG results of pH 7.47, PaCO2 45, HCO3 33 indicate metabolic alkalosis, which is not typically associated with ESKD. Metabolic alkalosis occurs when there is an excess of bicarbonate or a loss of acid. This condition can result from factors such as vomiting, diuretic use, or excessive antacid consumption. It is not a common finding in patients with ESKD.
Choice D reason: The ABG results of pH 7.31, PaCO2 48, HCO3 24 indicate respiratory acidosis, which is not typically associated with ESKD. Respiratory acidosis occurs when there is an accumulation of carbon dioxide due to impaired respiratory function. This condition is more likely to be seen in chronic obstructive pulmonary disease (COPD) or other respiratory disorders. It is not a common finding in patients with ESKD.
Correct Answer is A
Explanation
Choice A reason: The order to administer Hydrochlorothiazide should be clarified because thiazide diuretics can increase calcium levels, which could worsen hypercalcemia in a patient with a history of hyperparathyroidism.
Choice B reason: Monitoring intake and output and daily weights are essential for managing fluid balance in heart failure patients and do not need clarification.
Choice C reason: Administering Calcitonin helps lower calcium levels, which is appropriate for treating hypercalcemia in a patient with hyperparathyroidism.
Choice D reason: Preparing the patient for possible hemodialysis may be necessary if the patient's kidney function deteriorates, especially with elevated BUN and creatinine levels.
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