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:

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Question 1 of 5

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:

Correct Answer: B

Rationale: In a client with idiopathic thrombocytopenic purpura (ITP), a platelet count falling below 20,000/ul puts them at the greatest risk for cerebral hemorrhage. This is because the risk of spontaneous bleeding, especially in critical areas like the brain, significantly increases as platelet counts drop below this level. The brain is a sensitive organ, and even minor bleeds can have serious consequences. Therefore, it is crucial for healthcare providers to closely monitor platelet counts and promptly intervene to prevent life-threatening hemorrhage in clients with ITP.

Question 2 of 5

the vital sign that the nurse should most certainly check before administering digoxin is:

Correct Answer: A

Rationale: Before administering digoxin, it is crucial for the nurse to check the patient's pulse rate. Digoxin is a medication commonly used to treat heart conditions such as atrial fibrillation and heart failure by increasing the strength and efficiency of the heart's contractions. However, digoxin can also cause adverse effects such as bradycardia (slow heart rate) or heart block. Therefore, it is important to assess the patient's pulse rate to ensure that it is within the safe range before administering digoxin.

Question 3 of 5

Which of the following malignant tumors is least likely to occur in adults in comparison with children?

Correct Answer: D

Rationale: Retinoblastoma predominantly occurs in children under 5 years of age, making it the least likely to occur in adults.

Question 4 of 5

The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording

Correct Answer: C

Rationale: Monitoring urinary output every hour is crucial in assessing the adequacy of fluid replacement in a client with full-thickness burns. Burn injuries can result in a significant loss of fluid and electrolytes due to increased capillary permeability and excessive fluid shift from the intravascular space to the interstitial space. Adequate fluid replacement is essential to maintain tissue perfusion, prevent hypovolemia, and support organ function. By closely monitoring the urinary output every hour, the nurse can assess renal perfusion, fluid balance, and the effectiveness of fluid resuscitation. A decrease in urinary output can indicate inadequate fluid replacement, while an increase may suggest fluid overload. This information is important in guiding adjustments to the fluid replacement therapy to ensure optimal outcomes for the client. Weights, blood pressure measurements, and assessment of peripheral edema are also important data to monitor in a burn client, but urinary output is the most significant indicator of fluid balance in

Question 5 of 5

A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600mg PO every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?

Correct Answer: B

Rationale: Tinnitus is a known adverse drug reaction to aspirin, especially at higher doses. Tinnitus is described as ringing, buzzing, or other noises in the ears. If a client experiences tinnitus while taking aspirin, it is important to notify the physician promptly as it could be a sign of aspirin toxicity. Monitoring and managing this adverse reaction are crucial to prevent further complications for the client.

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