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.`

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Performing daily weights is the best method to evaluate the client's response to furosemide, a drug that reduces fluid retention and swelling by increasing the urine output. ¹ Daily weights can help monitor the changes in the client's fluid status and the effectiveness of the drug. The nurse should weigh the client at the same time each day, using the same scale and clothing.

Choice B reason: Taking the blood pressure is not the best method to evaluate the client's response to furosemide. Furosemide can also lower the blood pressure by reducing the volume of fluid in the blood vessels. ¹ However, blood pressure can be influenced by many other factors, such as heart rate, stress, or medications. Blood pressure is not a reliable indicator of the client's fluid status or the effectiveness of the drug.

Choice C reason: Auscultating breath sounds is not the best method to evaluate the client's response to furosemide. Furosemide can help improve the breath sounds by reducing the fluid accumulation in the lungs, which can cause shortness of breath or crackles. ¹ However, breath sounds can also be affected by other factors, such as lung infections, asthma, or allergies. Breath sounds are not a reliable indicator of the client's fluid status or the effectiveness of the drug.

Choice D reason: Measuring urinary output is not the best method to evaluate the client's response to furosemide. Furosemide can increase the urinary output by stimulating the kidneys to excrete more water and electrolytes. ¹ However, urinary output can also vary depending on the fluid intake, kidney function, or other medications. Urinary output is not a reliable indicator of the client's fluid status or the effectiveness of the drug.

A. Has gained 2 pounds and has pink buccal mucosa B. No longer has paresthesia of the hands and feet C. Realizes eating more iron fortified cereals D. Has stopped drinking any alcoholic beverages

Correct Answer is B

Explanation

Choice A reason: While gaining weight and having pink buccal mucosa can be signs of overall improved health, they are not specific indicators of effective treatment for vitamin B12 deficiency¹².

Choice B reason: Paresthesia (a sensation of tingling, tickling, pricking, or burning of a person's skin) of the hands and feet is a common symptom of vitamin B12 deficiency¹². If the client no longer has this symptom, it could indicate that the treatment for vitamin B12 deficiency has been effective¹².

Choice C reason: Eating more iron-fortified cereals can contribute to overall nutritional health, but it's not directly related to the treatment of vitamin B12 deficiency¹².

Choice D reason: While stopping alcohol consumption can improve overall health, it's not a specific indicator of effective treatment for vitamin B12 deficiency¹²..

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When caring for a client diagnosed with thrombocytopenia, the nurse should plan to:

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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