Nokea
The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
- A. Limit visits by family members
- B. Encourage the client to use a wheelchair
- C. Use the smallest needle possible for injections
- D. Maintain accurate fluid intake and output records Situation: AIDS cases has been all over the country and yet only few are reported cases due to the stigma attach to it.
Correct Answer: C
Rationale: The correct answer is C: Use the smallest needle possible for injections. In a client with thrombocytopenia (low platelet count), there is an increased risk of bleeding and bruising. Using the smallest needle possible for injections reduces the risk of causing injury to blood vessels and tissues, minimizing bleeding complications. Limiting visits by family members (choice A) is not directly related to protecting the client's safety. Encouraging wheelchair use (choice B) is not necessary unless indicated for mobility reasons. Maintaining accurate fluid intake and output records (choice D) is important for overall client care but does not directly address the risk of bleeding in thrombocytopenia.
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A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client’s platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:
- A. 135,000/ul
- B. 20,000/ul
- C. 75,000/ul
- D. 500/ul
Correct Answer: B
Rationale: The correct answer is B: 20,000/ul. A platelet count below 20,000/ul puts the client at the highest risk for cerebral hemorrhage due to severe thrombocytopenia. Platelets are essential for blood clotting, and a low count increases the risk of spontaneous bleeding, especially in critical organs like the brain. Choices A, C, and D have platelet counts that are higher than the critical level of 20,000/ul, so they do not pose as high a risk for cerebral hemorrhage. Option D, 500/ul, is extremely low and would likely lead to severe bleeding, but the critical threshold for cerebral hemorrhage is considered to be around 20,000/ul.
Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
- A. Add any needed IV medication in the blood bag within one hour of planned infusion
- B. Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to infusion
- C. Prime tubing of blood administration set with 0.9% NS solution, completely, filling filter
- D. Inadequate dietary intake
Correct Answer: C
Rationale: The correct answer is C because priming the tubing of the blood administration set with 0.9% NS solution ensures that there are no air bubbles in the tubing, preventing air embolism when the blood transfusion starts. This step also ensures that the blood flows smoothly and prevents clotting in the tubing.
Choice A is incorrect because adding IV medication in the blood bag can lead to incompatibility issues and should not be done without proper verification and approval.
Choice B is incorrect because leaving the blood bag at room temperature for an hour can lead to bacterial growth in the blood, increasing the risk of infection when transfused.
Choice D is unrelated to setting up supplies for a blood transfusion and does not address the immediate nursing intervention required in this situation.
After being in remission from Hodgkin’s disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin’sdisease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these finding result from:
- A. Bleeding in the liver caused by the liver biopsy.
- B. Perforation of the colon caused by the liver biopsy.
- C. An allergic reaction to the contrast media used during liver biopsy.
- D. Normal post procedural pain, with a change in the level of consciousness resulting from the preexisting fever.
Correct Answer: B
Rationale: The correct answer is B: Perforation of the colon caused by the liver biopsy. The symptoms of fever, severe abdominal pain, and confusion are indicative of peritonitis, which can result from a bowel perforation during the liver biopsy procedure. Perforation of the colon can lead to leakage of bowel contents into the peritoneal cavity, causing inflammation, infection, and systemic symptoms. This is a serious complication that requires immediate medical attention.
Incorrect options:
A: Bleeding in the liver caused by the liver biopsy would present with symptoms such as hypotension and signs of internal bleeding, not confusion and severe abdominal pain.
C: An allergic reaction to contrast media would typically present with symptoms such as rash, itching, or respiratory distress, not fever, severe abdominal pain, and confusion.
D: Normal post procedural pain would not cause confusion and a change in the level of consciousness, which indicates a more serious underlying issue like bowel perforation.
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
- A. Shrimp and tomatoes
- B. Cheese and bananas
- C. Lobster and squash
- D. Lamb and peaches
Correct Answer: A
Rationale: The correct answer is A: Shrimp and tomatoes. Shrimp is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Tomatoes are rich in Vitamin C, which helps enhance iron absorption. Cheese, bananas, lobster, squash, lamb, and peaches do not provide significant amounts of iron essential for an anemic client. The combination of shrimp and tomatoes offers a balanced approach to increase iron levels effectively.
A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient’s care plan?
- A. Infection
- B. Risk for infection
- C. Impaired skin integrity
- D. Staphylococcal leg infection
Correct Answer: C
Rationale: The correct nursing diagnosis is C: Impaired skin integrity. This choice is correct because it directly addresses the bacterial infection in the left lower leg by focusing on the skin's condition. The patient's skin integrity is compromised due to the infection, making this nursing diagnosis appropriate.
Choice A (Infection) is too broad and does not specify the impact on the skin. Choice B (Risk for infection) is incorrect because the patient already has a bacterial infection, so the risk has already manifested. Choice D (Staphylococcal leg infection) is too specific and does not address the broader issue of skin integrity.
Therefore, the best choice is C as it accurately reflects the patient's current condition and guides appropriate nursing interventions to address the impaired skin integrity caused by the bacterial infection.