a nurse is planning care for a client with thrombocytopenia which action should be included
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ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A nurse is planning care for a client with thrombocytopenia. Which action should be included?

Correct answer: C

Rationale: The correct action to include in the care plan for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent straining during bowel movements, reducing the risk of bleeding episodes. Encouraging the client to floss daily (choice A) is important for oral hygiene but is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (choice B) is more relevant for clients with neutropenia to reduce the risk of infection. Avoiding serving the client raw vegetables (choice D) is important for clients with compromised immune systems but is not specifically related to thrombocytopenia.

2. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Correct answer: Applying zinc oxide ointment to the irritated area is the most appropriate action for diaper dermatitis. Zinc oxide is a barrier cream that helps protect the skin and promote healing. Choice B is incorrect because using store-bought baby wipes may contain chemicals or fragrances that can further irritate the skin. Choice C is incorrect as talcum powder can also worsen the condition by drying out the skin. Choice D is incorrect because a warm compress is not typically used for diaper dermatitis; it may provide relief for other conditions but is not the best option for diaper dermatitis.

3. A client has a new prescription for levothyroxine. Which of the following statements should the nurse include?

Correct answer: D

Rationale: The correct statement the nurse should include is to take levothyroxine with a full glass of water before breakfast. This helps improve absorption and prevents gastrointestinal side effects. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect as insomnia is not a common side effect of levothyroxine. Choice C is also incorrect as levothyroxine does not need to be refrigerated.

4. A healthcare professional is reviewing a client's laboratory results. Which of the following values is a contraindication to the administration of heparin?

Correct answer: B

Rationale: The correct answer is B: Platelet count 50,000/mm³. A platelet count of 50,000/mm³ increases the risk of bleeding, making heparin contraindicated. Platelets are essential for blood clotting, and a low count can lead to excessive bleeding. Choices A, C, and D are not contraindications to heparin administration. Hemoglobin level of 13 g/dL is within the normal range, white blood cell count of 6,000/mm³ is also normal, and an INR of 2.5 is within the therapeutic range for patients receiving heparin therapy.

5. A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.

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