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.
The nurse needs to inform the patient with impaired vision when a touch is to occur and ask permissi
The nurse can make observations about the patient's general appearance while talking with the p
Hubba Hubba Nurse Smiley
Lawn spread or colony count streaking.
Testing the Achilles tendon reflex with client in a sitting position
Client’s view with visual field loss