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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Assessing for hypotension is not indicative of fluid overload. Hypotension is more likely associated with hypovolemia or hemorrhage, whereas fluid overload manifests as signs of hypervolemia, including elevated blood pressure and pulmonary edema.

Choice B rationale

Assessing for distention above the pubis area identifies bladder retention or obstruction but is not directly related to monitoring fluid overload. Fluid overload affects systemic circulation and organ function rather than localized distention.

Choice C rationale

Monitoring laboratory values for hypernatremia is not an effective strategy for detecting fluid overload. Hypernatremia occurs due to inadequate water intake rather than excessive fluid administration. Fluid overload is typically identified by signs such as pulmonary congestion and generalized edema.

Choice D rationale

Maintaining strict intake and output records is crucial in detecting fluid overload. It helps identify disproportionate fluid retention compared to urinary output, signaling hypervolemia. Continuous monitoring ensures timely adjustments in fluid administration and prevents complications. .

A. "It is important to avoid exposure to cold climates.”. B. "You need to consume an increased amount of oral fluids daily.”. C. "Include iron and vitamin B12-rich foods in your diet each day.”. D. "Be sure to check the list of medications and substances to avoid before starting anything new.”. . . .

Correct Answer is D

Explanation

Choice A rationale

Avoiding exposure to cold climates is not specific to thalassemia prevention. While cold environments may exacerbate general vasoconstriction, they do not influence the genetic and hematologic basis of thalassemia symptoms.

Choice B rationale

Increasing fluid intake does not directly address thalassemia pathophysiology. While hydration is vital, it does not correct the primary anemia or the compromised oxygen delivery stemming from abnormal hemoglobin synthesis.

Choice C rationale

Iron and vitamin B12-rich foods are beneficial for conditions involving deficiency anemia. However, thalassemia involves a genetic defect in hemoglobin chains, so excess iron could even result in iron overload complications.

Choice D rationale

Medications and substances that exacerbate hemolysis, such as sulfonamides or antimalarials, should be avoided in thalassemia. Awareness and prevention of exposure are key to minimizing symptoms and complications in affected individuals. .

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing postoperative care for a male client who had a transurethral resection of the prostate (TURP) 4 hours ago and has continuous irrigation.Which of the following actions should the nurse take to monitor the client for fluid overload?

Correct Answer is D

Explanation

The nurse is teaching a client about preventing symptoms of thalassemia.Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

The nurse is teaching a client about preventing symptoms of thalassemia.Which of the following information should the nurse include in the teaching?

The nurse is providing postoperative care for a male client who had a transurethral resection of the prostate (TURP) 4 hours ago and has continuous irrigation.Which of the following actions should the nurse take to monitor the client for fluid overload?

The nurse is performing a health screening for a client at a local clinic and the client states, "I have noticed changes in my vision recently and I have also had some bad headaches.”. Which of the following actions should be a priority for the nurse to take?

The nurse is caring for a client who has thrombocytopenia.Which of the following will the nurse administer for this disorder?

The nurse has taught a client with urinary incontinence about taking prescribed oxybutynin chloride.Which of the following statements by the client would indicate a correct understanding of the teaching?

The nurse is caring for a client who was diagnosed with left-sided heart failure and states, "I do not understand why I have so much trouble breathing if I have heart failure.”. Which of the following responses should the nurse make?