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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Withholding the dose and reassessing the blood pressure in 30 minutes is not the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Delaying the administration of furosemide may worsen the client's condition and increase the risk of complications, such as pulmonary edema or heart failure.
Choice B reason: Calling the healthcare provider to obtain an order for oral furosemide is not the most appropriate action at this time. Oral furosemide is a tablet that is swallowed and absorbed by the digestive system. ¹ It takes longer to act than intravenous (IV) furosemide, which is injected directly into the bloodstream. ¹ The client has pulmonary congestion, which requires immediate treatment to relieve the fluid accumulation in the lungs. Switching to oral furosemide may delay the therapeutic effect and compromise the client's outcome.
Choice C reason: Administering the medication and notifying the healthcare provider of the blood pressure is the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Administering IV furosemide can help remove the excess fluid from the lungs and improve the client's breathing and oxygenation. However, furosemide can also lower the blood pressure by reducing the volume of fluid in the blood vessels. ¹ The client already has low blood pressure, which can cause dizziness, fainting, or shock. The nurse should notify the healthcare provider of the blood pressure and monitor the client for any signs of hypotension or adverse reactions.
Choice D reason: Administering the dose and continuing to monitor the vital signs is not the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Administering IV furosemide can help remove the excess fluid from the lungs and improve the client's breathing and oxygenation. However, furosemide can also lower the blood pressure by reducing the volume of fluid in the blood vessels. ¹ The client already has low blood pressure, which can cause dizziness, fainting, or shock. The nurse should not only monitor the vital signs, but also notify the healthcare provider of the blood pressure and report any changes or concerns.
Correct Answer is B
Explanation
Choice A reason: Increasing the SA to AV node conduction time is not the goal of using diltiazem for variant angina. Diltiazem is a calcium channel blocker that slows down the conduction of electrical impulses in the heart, but this is not the main mechanism of action for relieving variant angina. Variant angina is caused by spasms of the coronary arteries that reduce blood flow to the heart muscle.
Choice B reason: This is the correct answer. Decreasing coronary artery spasm is the goal of using diltiazem for variant angina. Diltiazem relaxes the smooth muscle of the coronary arteries and prevents them from contracting. This improves the blood supply to the heart and reduces the pain and ischemia associated with variant angina.
Choice C reason: Diltiazem does not cause hyperexcitability in the myocardium. This is a false statement. Diltiazem has the opposite effect of reducing the contractility and excitability of the heart muscle. This lowers the oxygen demand of the heart and helps prevent anginal attacks.
Choice D reason: Increasing the heart rate is not the goal of using diltiazem for variant angina. Diltiazem actually decreases the heart rate by blocking the calcium channels in the sinoatrial node and the atrioventricular node. This reduces the workload of the heart and the oxygen consumption. A high heart rate can worsen angina by increasing the oxygen demand of the heart.
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