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Answered step-by-step
Asked by Ezennah

Scenario: The nurse is caring for a 30-year-old HIV positive type 1 diabetic male who was admitted into the hospital today for a 4-day history of excessive bruising, frequent nose bleeds, and bleeding gums. His platelet count is 30,000/µL. His admitting diagnosis is immune thrombocytopenia. He is awake and alert and denies any pain or discomfort. Vital signs are temperature 97.2, pulse 96 bpm, respirations 16 per minute, and blood pressure 118/60 mm Hg. He has several areas of purpura on his back and arms. He states his last nosebleed was last night, which lasted 2 hours. He states that even though he uses a soft toothbrush his gums bleed excessively each time he brushes his teeth.

 

NGN Item Type:

Use an X for the nursing actions listed below that are Indicated (necessary), Contraindicated (could be harmful), or Nonessential (not necessary) for the client’s care at this time. Only one selection can be made for each nursing action.

Nursing Action Indicated Contraindicated Nonessential

Apply direct

pressure for 5-10

minutes after each

insulin injection.

Ask patient to blow

nose forcefully to

remove old clots.

Offer the patient a razor blade for shaving.

Closely monitor

hemoglobin and

hematocrit count.

Encourage the

patient to use an

incentive

spirometer to aid in

lung expansion.

Plan to administer

aspirin 81 mg each

day to prevent

blood clots.

 

 

Rationales for your choices:

SCIENCE
HEALTH SCIENCE
NURSING
BIO 1100 XO03

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