When caring for a client diagnosed with thrombocytopenia, the nurse should plan to:
encourage vigorous tooth brushing with a soft bristle toothbrush.
avoid needle sticks or other invasive procedures as much as possible.
hold all stool softeners and laxatives until otherwise ordered.
obtain a low temperature every 8 hours.`
The Correct Answer is B
Choice A reason: The nurse should not encourage vigorous tooth brushing with a soft bristle toothbrush. Thrombocytopenia is a condition where the blood has a low number of platelets, which are cells that help with clotting. ¹ Vigorous tooth brushing can cause bleeding of the gums, which can be hard to stop in a client with thrombocytopenia. The nurse should advise the client to use a soft sponge or swab to clean the teeth and mouth gently.
Choice B reason: The nurse should avoid needle sticks or other invasive procedures as much as possible. Needle sticks and other invasive procedures can cause bleeding, bruising, or infection in a client with thrombocytopenia. ¹ The nurse should use the smallest gauge needle possible, apply pressure for at least 10 minutes after the procedure, and monitor the site for any signs of bleeding or infection. The nurse should also avoid unnecessary blood draws or injections, and use non-invasive methods whenever possible.
Choice C reason: The nurse should not hold all stool softeners and laxatives until otherwise ordered. Stool softeners and laxatives can help prevent constipation and straining, which can cause hemorrhoids or anal fissures in a client with thrombocytopenia. ¹ The nurse should encourage the client to take stool softeners and laxatives as prescribed, drink plenty of fluids, and eat high-fiber foods to promote regular bowel movements.
Choice D reason: The nurse should not obtain a low temperature every 8 hours. A low temperature is not a relevant or accurate measurement for a client with thrombocytopenia. The nurse should obtain a normal temperature, which is around 98.6°F (37°C), using a non-invasive method, such as an oral or tympanic thermometer. ² The nurse should avoid using a rectal thermometer, as it can cause bleeding or infection in a client with thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A history of cardiac disease is not directly related to enlarged axillary lymph nodes. Cardiac disease may affect the heart, blood vessels, and circulation, but not the lymphatic system. ¹
Choice B reason: A recent infection is a possible cause of enlarged axillary lymph nodes. Lymph nodes are part of the immune system and they swell when they are fighting an infection. ² The nurse should ask the client about any signs or symptoms of infection, such as fever, sore throat, or skin rash.
Choice C reason: Shortness of breath is not directly related to enlarged axillary lymph nodes. Shortness of breath may indicate a respiratory problem, such as asthma, bronchitis, or pneumonia. ³ However, these conditions do not usually affect the lymph nodes in the armpit area.
Choice D reason: Surgery on the neck is not directly related to enlarged axillary lymph nodes. Surgery on the neck may affect the lymph nodes in the neck or the collarbone area, but not the lymph nodes in the armpit area. The nurse should ask the client about any history of surgery or trauma to the lymph nodes or the surrounding tissues.
Correct Answer is A
Explanation
Choice A reason: Throwing away any tablets that fizzle under my tongue, it means they are ineffective is not a statement that indicates an understanding of the discharge teaching. This statement is incorrect and dangerous, as fizzling or tingling is a normal sensation that indicates that the tablet is working. The client should not discard or waste the medication, but keep it in a dark, dry, and cool place.
Choice B reason: Keeping my bottle of nitroglycerin at home in the medicine cabinet is not a statement that indicates an understanding of the discharge teaching. This statement is impractical and risky, as the client may need the medication when they are away from home. The client should always carry the medication with them and have it readily available in case of chest pain.
Choice C reason: Calling 911 if I get chest pain that doesn't go away after one tablet and I will take another tablet is a statement that indicates an understanding of the discharge teaching. This statement is correct and safe, as it follows the standard protocol for using nitroglycerin SL for angina. The client should take one tablet under the tongue at the onset of chest pain, wait five minutes, and repeat if the pain persists. If the pain is not relieved after three tablets, the client should seek emergency medical attention.
Choice D reason: Removing the tablets from the bottle and keeping them in a plastic bag in my handbag is not a statement that indicates an understanding of the discharge teaching. This statement is inappropriate and harmful, as it exposes the medication to light, moisture, and heat, which can reduce its potency and effectiveness. The client should keep the tablets in their original container and close it tightly after each use.
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