Which of the following actions should a nurse plan for when providing care for a client diagnosed with thrombocytopenia?

Avoid needle sticks or other invasive procedures as much as possible.

Hold all stool softeners and laxatives until otherwise

Encourage vigorous tooth brushing with a soft bristle toothbrush,

Obtain a core temperature every 8 hours.

Answer and Explanation

The Correct Answer is A

A. Avoid needle sticks or other invasive procedures as much as possible: This is the most appropriate action for a client with thrombocytopenia. Since thrombocytopenia involves a low platelet count, the risk of bleeding is increased, and minimizing invasive procedures helps prevent complications.

B. Hold all stool softeners and laxatives until otherwise: This statement is not appropriate. Clients with thrombocytopenia should avoid straining during bowel movements, which can be facilitated by the use of stool softeners or laxatives if necessary.

C. Encourage vigorous tooth brushing with a soft bristle toothbrush: This is not advisable. While using a soft-bristled toothbrush is recommended, vigorous brushing could cause gum bleeding. Gentle oral hygiene practices should be emphasized instead.

D. Obtain a core temperature every 8 hours: While monitoring temperature is important, it is not specific to thrombocytopenia management. Other vital signs may be monitored more frequently, but this action does not directly address the primary concern of bleeding risk.

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Correct Answer is ["A","B","C","E"]

Explanation

A. "What were you doing when the pain started?" This question helps identify potential triggers or activities that may have precipitated the chest pain, which is crucial for understanding the context of the pain.

B. "How long has the pain lasted?" Knowing the duration of the pain is vital in assessing the urgency of the situation and determining whether it may be related to a serious condition like angina or myocardial infarction.

C. "How would you describe the pain?" This question allows the client to characterize the pain (e.g., sharp, dull, squeezing), which can provide insights into the potential causes and the nature of the chest pain.

D. "How has the pain affected your relationship with your spouse?" While this question might provide some psychosocial context, it is less directly related to the immediate assessment of the chest pain itself and can be considered secondary.

E. "Can you rate the pain on a 0-10 scale with 10 being the worst?" Pain rating is essential in assessing the severity of the pain, which can help guide treatment and interventions.

Correct Answer is ["480"]

Explanation

To calculate the infusion rate, you need to determine the total volume to be infused and the time over which it will be infused.

Total volume to be infused = 200 mL

Time for infusion = 25 minutes

Infusion rate = Total volume / Time Infusion rate = 200 mL / 25 minutes = 8 mL/min

To convert this to mL/hour (since infusion pumps are typically set in mL/hour): Infusion rate = 8 mL/min × 60 minutes/hour = 480 mL/hour

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Which of the following actions should a nurse plan for when providing care for a client diagnosed with thrombocytopenia?

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Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","E"]

Explanation

A client is ordered to receive a bolus of 200 mL of NSS in 25 minutes. At what rate should the nurse set the IV pump?

Correct Answer is ["480"]

Explanation

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