The nurse is caring for a patient with thrombocytopenia who has a platelet count of 45,000/mm³. What nursing intervention will the nurse implement to manage this condition?

Administer platelet transfusion immediately.

Monitor the patient for signs of bleeding and educate about bleeding precautions.

Administer aspirin to reduce the risk of clot formation.

Encourage the patient to engage in regular physical exercise to improve circulation.

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering a platelet transfusion immediately is not indicated for a platelet count of 45,000/mm³. While this is below the normal range, it is not critically low. Platelet transfusions are typically reserved for patients with life-threatening bleeding or extremely low platelet counts.

Choice B reason: Monitoring the patient for signs of bleeding and educating about bleeding precautions is the appropriate intervention. Patients with thrombocytopenia are at an increased risk of bleeding, and it is essential to educate them on how to minimize this risk, such as avoiding activities that can cause injury, using a soft toothbrush, and avoiding over-the-counter medications that can affect platelet function.

Choice C reason: Administering aspirin to reduce the risk of clot formation is incorrect. Aspirin is an antiplatelet agent that can increase the risk of bleeding in patients with thrombocytopenia. It should be avoided unless specifically prescribed for another condition with close monitoring.

Choice D reason: Encouraging the patient to engage in regular physical exercise to improve circulation is not appropriate in this context. While physical activity is generally beneficial, it should be done with caution in patients with thrombocytopenia to avoid injury and bleeding. The focus should be on safety and bleeding precautions.

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Correct Answer is B

Explanation

Choice A reason: Weighing the patient using a bed scale and restricting oral fluids are important interventions for managing fluid balance in heart failure, but they are not the immediate priority. Assessing the respiratory status takes precedence to ensure the patient is not in respiratory distress.

Choice B reason: Obtaining pulse oximetry levels and assessing the respiratory status are priority actions. Dyspnea on exertion and fatigue indicate potential respiratory compromise, and it is crucial to evaluate oxygenation and respiratory function immediately.

Choice C reason: Elevating the lower extremity on two pillows while the patient is in bed can help reduce edema but is not the immediate priority. Respiratory assessment and stabilization take precedence.

Choice D reason: Obtaining a Physical Therapy consultation to evaluate activity tolerance is beneficial for long-term management but is not an immediate priority in acute care. The focus should be on assessing and stabilizing the patient's respiratory and cardiac status.

A. The patient is increasingly drowsy and hard to arouse. B. The patient's feet and hands are covered with red, raised purpura.

Correct Answer is A

Explanation

Choice A reason: The patient being increasingly drowsy and hard to arouse is an urgent finding that should be reported immediately. This condition may indicate intracranial bleeding or other severe complications related to extremely low platelet count (10,000/mm³) in idiopathic thrombocytopenic purpura (ITP). Immediate medical intervention is required to prevent further deterioration.

Choice B reason: Red, raised purpura on the patient's feet and hands is a concerning finding indicative of significant thrombocytopenia, but it is not as immediately life-threatening as decreased consciousness. It should still be monitored and managed, but the priority is the patient's level of consciousness.

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The nurse is caring for a patient with thrombocytopenia who has a platelet count of 45,000/mm³. What nursing intervention will the nurse implement to manage this condition?

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