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 B

Explanation

A) Total cholesterol 198 mg/dL: While this value is within normal limits, it does not specifically indicate the effectiveness of atorvastatin treatment, which primarily aims to lower LDL levels. An optimal outcome would focus more on the LDL reduction rather than total cholesterol alone.

B) Low density lipoprotein (LDL) 90 mg/dL: This finding indicates an expected outcome of atorvastatin therapy. Atorvastatin is effective at lowering LDL cholesterol, which is a key target in managing hyperlipidemia and reducing the risk of cardiovascular events. An LDL level below 100 mg/dL is generally considered optimal.

C) Serum albumin 6 g/L: This value is low and indicates potential malnutrition or liver dysfunction, which are not expected outcomes for a client on atorvastatin. A normal serum albumin level typically ranges from 3.5 to 5.0 g/dL, so this finding is concerning.

D) Alanine aminotransferase (ALT) 25 units/L: While this ALT level is within the normal range, it does not directly reflect the primary goal of atorvastatin therapy, which is to lower LDL cholesterol. Monitoring liver enzymes is important, but the expected outcome would be more clearly indicated by improved lipid profiles, particularly LDL levels.

A. Monitor serum sodium levels B. Auscultate breath sounds C. Perform daily weights D. Take the blood pressure

Correct Answer is C

Explanation

A. Monitor serum sodium levels: While serum sodium levels can provide some information about fluid balance, they are not the most direct indicator of the effectiveness of furosemide
in reducing peripheral edema.

B. Auscultate breath sounds: This is important for monitoring potential fluid overload or pulmonary complications, but it does not directly assess the reduction of peripheral edema, which is the primary concern with furosemide administration.

C. Perform daily weights: This method is the best way to evaluate the client's response to furosemide. Daily weights can provide a clear indication of fluid status and changes in peripheral edema, as a decrease in weight typically reflects effective diuresis.
D. Take the blood pressure: While monitoring blood pressure is important, especially in clients receiving diuretics, it does not specifically measure the effectiveness of the medication in addressing peripheral edema.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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