Nokea
A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?
- A. Check the client for ecchymosis.
- B. Initiate protective isolation for the client.
- C. Administer ibuprofen for mild headache.
- D. Instruct the client to shave with a disposable razor.
Correct Answer: A
Rationale: Checking for ecchymosis (bruising) monitors for bleeding, a risk in thrombocytopenia due to low platelets. Isolation isn't needed, ibuprofen increases bleeding risk, and razors should be avoided.
You may also like to solve these questions
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- C. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- D. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range and increases the risk of bleeding during a liver biopsy, so it should be reported. The other values are within normal limits and do not pose an immediate concern.
A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care?
- A. Apply moist heat prior to ambulation.
- B. Delay ambulation until the next day
- C. Use a continuous passive motion machine
- D. Rest in a soft chair
- E. Apply cold packs.
- F. Increase weight-bearing exercise.
- G. Avoid all movement.
Correct Answer: A
Rationale: Moist heat reduces stiffness and improves mobility in osteoarthritis.
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
- A. Experiences nocturia
- B. History of generalized anxiety disorder
- C. Recent exposure to tuberculosis
- D. Reports periodic migraine headaches
Correct Answer: C
Rationale: Recent TB exposure is the priority due to infection risk to others in a semi-private room, requiring immediate isolation precautions.
A nurse is collecting data from a client who had a long arm cast applied 2 hr. ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?
- A. The client's fingers are cool to the touch.
- B. The client reports severe itching under the cast.
- C. The client's capillary refill is 3 seconds.
- D. The client reports increased pain at the area of the fracture.
Correct Answer: A
Rationale: Cool fingers suggest impaired circulation, a potential emergency post-cast application requiring immediate reporting. Itching and pain are common, and 3-second refill is borderline normal.
A nurse is assisting with the care of a postoperative client who has developed malignant hyperthermia. Which of the following actions should the nurse take?
- A. Administer meperidine IM.
- B. Instill a warm enema solution.
- C. Apply a cooling blanket.
- D. Ventilate client with 50% oxygen.
Correct Answer: C
Rationale: A cooling blanket lowers body temperature in malignant hyperthermia, a life-threatening condition. Meperidine, warm enemas, and oxygen alone don't address the hyperthermia directly.