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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Checking the patient's blood pressure before and after IV administration is important, but it is not the most critical action to ensure safety during the procedure.

Choice B reason: Ensuring the dialysis access site is used for IV administration when possible is not standard practice. The dialysis access site is typically reserved for dialysis treatments to prevent complications.

Choice C reason: Verifying the correct fluid type and rate as per the physician's order is the most important action. Ensuring the right fluid type and rate prevents potential complications such as fluid overload, electrolyte imbalances, and adverse reactions.

Choice D reason: Monitoring for signs of infiltration or extravasation at the IV site is important, but verifying the correct fluid type and rate takes precedence to prevent any errors in the initial setup.

A. Respiratory alkalosis, uncompensated B. Respiratory acidosis, partially compensated C. Metabolic acidosis, uncompensated D. Metabolic alkalosis, partially compensated

Correct Answer is D

Explanation

Choice A reason: Respiratory alkalosis with uncompensated imbalance would show a low PaCO2, not a normal value.

Choice B reason: Respiratory acidosis with partially compensated imbalance would show a low pH and high PaCO2 with an elevated bicarbonate level.

Choice C reason: Metabolic acidosis with uncompensated imbalance would show a low pH and low bicarbonate level.

Choice D reason: Metabolic alkalosis with partially compensated imbalance is indicated by the elevated pH and bicarbonate level, while

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is administering intravenous (IV) fluids to a patient undergoing hemodialysis. Which action is most important for the nurse to take to ensure patient safety during the procedure?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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