Answer to Question 1
ANS: A
With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or putting the client back into bed is important, but the critical action is to call for immediate medical attention.
Answer to Question 2
ANS: D
While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately. The client may or may not need a transfusion. Reinforcing the dressing is an appropriate action, but the nurse needs to do more than document afterward. Removing the dressing increases the risk of infection; plus, it is not needed since the nurse knows where the bleeding is coming from.
A Bobcat finds water in Tucson, AZ.
Sample client goals from the Wellness Massage Pyramid.
Using small, circular strokes, exfoliate the client’s neck and back.
(A) Unwrap each of the layers until the client is covered by just the plastic sheet and the towels ...
Building a Client Base
Measuring the client’s weight with a standard platform scale