Nokea
For a client diagnosed with idiopathic thrombocytopenic purpura (ITP), which nursing intervention is appropriate?
- A. Teaching coughing and deep-breathing techniques to help prevent infection
- B. Administering platelets, as ordered to maintain an adequate platelet count
- C. Giving aspirin, as prescribed to control body temperature
- D. Administering stool softeners, as ordered, to prevent straining during infection
Correct Answer: B
Rationale: The appropriate nursing intervention for a client diagnosed with idiopathic thrombocytopenic purpura (ITP) is administering platelets, as ordered, to maintain an adequate platelet count. ITP is a condition characterized by a decrease in platelet count, which can lead to thrombocytopenia and an increased risk of bleeding. Administering platelets can help prevent excessive bleeding and maintain hemostasis in these patients. Platelet transfusions may be required in severe cases to raise the platelet count to a safe level and prevent bleeding complications. It is crucial for nurses to monitor the platelet count regularly and administer platelets as prescribed to manage ITP effectively.
You may also like to solve these questions
Janae has a seizure disorder; which of the following would be the lowest priority when caring for her? Observing and taking down data on all seizures
- A. Assuring safety and protection from injuring
- B. Assessing for signs and symptoms of increased intracranial pressure (ICP)
- C. Educating the family about anticonvulsant therapy
Correct Answer: C
Rationale: When caring for someone with a seizure disorder like Janae, the highest priority is ensuring their immediate safety and protection from injury during a seizure. This includes preventing falls, removing nearby hazards, and providing support during and after the seizure. Assessing for signs and symptoms of increased intracranial pressure is also important as it may indicate a serious complication requiring prompt medical attention. On the other hand, educating the family about anticonvulsant therapy, while important for long-term management, is considered a lower priority compared to the immediate safety and medical assessment needs of Janae during a seizure episode.
In Langerhans cell histiocytosis (LCH), all the following manifestations are at high risk of mortality in patients EXCEPT
- A. liver
- B. spleen
- C. lung
- D. hematopoietic system
Correct Answer: C
Rationale: Lung involvement, while serious, is less lethal compared to liver, spleen, or hematopoietic system involvement.
Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
- A. document the onset, duration, severity, and precipitating factors
- B. may offer analgesics for chest pain
- C. administer oxygen via face mask
- D. inform the physician about the heaviness
Correct Answer: C
Rationale: In a post-operative patient, sudden chest heaviness can be a sign of various complications, such as a pulmonary embolism or cardiac issue. One of the immediate nursing interventions for a patient complaining of chest heaviness is to ensure adequate oxygenation. Administering oxygen via a face mask can help improve oxygenation and provide relief while further assessments are being done to determine the cause of the symptom. This intervention takes priority over documenting the symptom, offering analgesics, or informing the physician, as addressing the patient's oxygen needs is crucial in this situation.
A 6-year-old child is scheduled for an IV urography (IVP) in the morning. Which preparatory interventions should the nurse plan to implement? (Select all that apply.)
- A. Clear liquids in the morning before the procedure
- B. Cathartic in the evening before the procedure
- C. Soapsuds enema the morning of the procedure
- D. Insertion of a Foley catheter before the procedure
Correct Answer: A
Rationale: Clear liquids in the morning before the procedure: It is important for the child to have clear liquids before the procedure to ensure proper hydration and to help with visualization during the urography.
Which of the following is an adverse reaction to glipizide (Glucotrol)?
- A. Headache
- B. Hypotension
- C. Constipation
- D. Photosensitivity
Correct Answer: B
Rationale: Hypotension, which is low blood pressure, can be an adverse reaction to glipizide (Glucotrol). Glipizide is a medication used to treat type 2 diabetes by helping to control blood sugar levels. Hypotension could occur as a side effect of glipizide, causing symptoms such as dizziness, lightheadedness, and fainting. If a patient experiences hypotension while taking glipizide, medical attention should be sought immediately to address this potentially serious adverse reaction.