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: 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.

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.

Correct Answer: A

Rationale: Step 1: Vitamin K is essential for the synthesis of clotting factors in the liver. Step 2: A splenectomy increases the risk of bleeding due to decreased platelet sequestration. Step 3: Preoperative Vitamin K injection helps correct any clotting deficiencies. Summary: - Choice B is incorrect as Vitamin K does not prevent infection. - Choice C is incorrect as Vitamin K does not directly promote healing. - Choice D is incorrect as Vitamin K does not dry secretions.

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.

Correct Answer: B

Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease. Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area. Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease. Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.