The nurse is planning care for a client with immune thrombocytopenic purpura (ITP). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Teach the client to avoid rectal and injection medications.

Teach the client about using an electric razor.

Prepare the client for a prescribed blood transfusion.

Teach the client to avoid constipation.

Explain the importance of avoiding taking sulfa-containing medications.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale

Clients with immune thrombocytopenic purpura (ITP) have a low platelet count, increasing the risk of bleeding. Avoiding rectal and injection medications minimizes the risk of mucosal damage and bleeding complications due to trauma caused by insertion or puncture. This precaution is especially critical as bleeding may not be easily controlled in these clients.

Choice B rationale

An electric razor prevents the risks associated with minor cuts or abrasions that could occur during shaving, which would be difficult to control due to low platelet levels. These injuries could lead to prolonged bleeding or bruising in ITP clients, compromising their safety further.

Choice C rationale

Blood transfusions are generally not indicated as routine interventions for ITP because platelet transfusions may not consistently improve platelet count due to antibody-mediated destruction. Treatment often focuses on medication and careful monitoring rather than transfusion.

Choice D rationale

Constipation should be avoided to reduce strain during bowel movements, which can result in rectal bleeding due to vascular damage in the area. The fragile nature of blood vessels in clients with ITP necessitates such preventive measures to avoid complications.

Choice E rationale

Sulfa-containing medications are known to exacerbate thrombocytopenia in some patients. Avoiding these medications minimizes further platelet depletion, which is vital for managing the condition and preventing severe bleeding episodes.

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Correct Answer is D

Explanation

Choice A rationale

A low-sodium, high-calorie diet is not the priority for immediate management of renal colic. Nutritional changes are addressed as part of long-term care but do not alleviate acute pain and discomfort caused by obstruction or irritation in the urinary tract.

Choice B rationale

Increasing fluid intake of 3 to 4 L/day is beneficial for preventing stone formation and enhancing urinary output, but fluid intake changes alone do not address acute renal colic. The urgency lies in alleviating the pain and promoting ureteral relaxation.

Choice C rationale

Tamsulosin (Flomax) 0.4 mg p.o. daily relaxes smooth muscles in the ureter, aiding stone passage, but does not provide immediate pain relief. It is a supportive measure rather than a first-line intervention during acute renal colic.

Choice D rationale

Morphine sulfate (Morphine) 2 mg IV every 4 hours PRN is the correct choice, as it addresses severe pain due to renal colic by acting directly on opioid receptors to block pain transmission. Pain relief improves the client’s comfort and allows further management strategies.

A. Serum electrolytes. B. Complete blood count. C. Blood urea nitrogen. D. Brain natriuretic peptide.

Correct Answer is D

Explanation

Choice A rationale

Serum electrolyte analysis provides insights into fluid and electrolyte balance but does not specifically diagnose heart failure. Electrolyte changes may occur secondary to heart failure but are not definitive markers for the condition.

Choice B rationale

Complete blood count evaluates for anemia or infection, which may contribute to symptomatology but is not diagnostic for heart failure. Heart failure diagnosis focuses on cardiac-specific markers rather than hematologic parameters.

Choice C rationale

Blood urea nitrogen assesses renal function and reflects perfusion status but lacks specificity for heart failure. Although renal dysfunction may occur in advanced heart failure, BNP measurement is more definitive for cardiac assessment.

Choice D rationale

Brain natriuretic peptide (BNP) is a key diagnostic marker for heart failure. Elevated BNP levels occur due to ventricular stretch and strain associated with fluid overload, a hallmark of heart failure. Normal BNP levels are typically <100 pg/mL, with elevated levels strongly suggesting cardiac dysfunction. .

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The nurse is planning care for a client with immune thrombocytopenic purpura (ITP). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

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