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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Chronic renal disease typically leads to metabolic acidosis, not alkalosis, due to the accumulation of acids that the kidney cannot excrete.
Choice B reason: Prolonged vomiting leads to the loss of hydrochloric acid from the stomach, which can result in metabolic alkalosis due to the imbalance caused by the loss of stomach acid.
Choice C reason: Hyperventilation leads to respiratory alkalosis due to the excessive exhalation of carbon dioxide, reducing hydrogen ion concentration in the blood.
Choice D reason: Obstructive sleep apnea is typically associated with respiratory acidosis, not metabolic alkalosis, due to episodes of hypoventilation during sleep.
Correct Answer is A
Explanation
Choice A reason:
- Ondansetron on a PRN basis is used to manage nausea and vomiting. In patients with inflammatory bowel disease, especially during an inpatient stay, controlling nausea is important to maintain comfort and prevent dehydration. This makes it an appropriate symptomatic treatment.
Choice B reason:
- Vitamin B12 injections may be indicated in patients with Crohn’s disease who have malabsorption issues, particularly if the terminal ileum is involved. However, they are not routinely given to all patients with inflammatory bowel disease solely for the prevention of pernicious anemia.
Choice C reason:
- Antidiarrheal medications are generally contraindicated in inflammatory bowel disease, as they can mask important symptoms and may increase the risk of complications like toxic megacolon, especially if administered before meals.
Choice D reason:
- Beta adrenergic blockers are not used to reduce bowel motility. Their primary use is in cardiovascular conditions, and they do not address the gastrointestinal symptoms associated with inflammatory bowel disease.
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