🛡️ In idiopathic thrombocytopenic purpura (ITP), the platelet count is low, so the client is at high risk for bleeding.

🛡️ Forceful nose blowing can traumatize fragile nasal mucosa and trigger epistaxis.

🛡️ Nursing care for thrombocytopenia focuses on minimizing any activity that can cause tissue injury or bleeding.

🛡️ Teaching gentle oral and nasal care is essential to protect the client from preventable hemorrhage.

🛡️ For this reason, instructing the client not to blow the nose forcefully is an important nursing intervention.

Restrict activity to passive and active range of motion

🛡️ Activity may need to be limited if bleeding risk is severe, but complete restriction to range-of-motion activity is not the key intervention listed here.

🛡️ The priority teaching emphasis is prevention of bleeding from everyday trauma.

Advise that the client not use rinses rather than a hard toothbrush for oral care

🛡️ This statement is incorrect because the client should actually avoid a hard toothbrush and use a soft toothbrush or gentle rinses instead.

🛡️ A hard toothbrush can injure the gums and increase bleeding.

Assign the client to a private room

🛡️ A private room is not routinely required for ITP because the disorder is not infectious.

🛡️ The main concern is bleeding precautions, not isolation from others.

🧤 Changing gloves immediately after use is one of the most important actions to prevent cross-contamination between clients, surfaces, and body sites.

🧤 Gloves become contaminated during care, and keeping them on after use can spread microorganisms to clean areas.

🧤 Proper glove removal and hand hygiene interrupt the transmission of pathogens in the healthcare setting.

🧤 This action is a core part of standard precautions and infection prevention.

🧤 For this reason, changing gloves immediately after use is the most important intervention listed.

Stand two feet away from the client

🧤 Standing two feet away does not reliably prevent the spread of microorganisms.

🧤 Infection prevention depends on proper barrier use, hand hygiene, and equipment handling rather than simple distance alone.

Speak minimally when in the room

🧤 Speaking minimally is not the primary method for preventing cross-contamination.

🧤 Standard precautions focus on direct control of contaminated hands, gloves, equipment, and secretions.

Wear long-sleeved shirts

🧤 Wearing long-sleeved shirts is not a standard infection-control measure for preventing cross-contamination.

🧤 Personal protective equipment should be selected based on exposure risk, such as gowns and gloves, not regular long sleeves.

🚶 Intermittent claudication refers to ischemic muscle pain that occurs during activity and improves with rest.

🚶 It is commonly caused by peripheral arterial disease, where narrowed arteries reduce blood flow to the legs.

🚶 During exercise, the muscles require more oxygen, but the diseased arteries cannot meet that demand.

🚶 Once the client rests, oxygen demand drops and the pain subsides.

🚶 For this reason, intermittent claudication is correctly described as lower-extremity pain with exercise that eases with rest.

The therapy involving the application of cold followed by the application of heat

🚶 This describes a treatment method using temperature changes, not intermittent claudication.

🚶 Claudication is specifically a symptom related to arterial insufficiency and exercise.

Pulses which alternately become bounding and thready

🚶 Alternating pulse strength describes a circulatory pulse characteristic, not claudication.

🚶 Intermittent claudication refers to exertional leg pain from poor arterial perfusion.

The alternate hyperemic and cyanotic appearance of the extremities

🚶 Changes in skin color may occur with vascular disease, but this is not the definition of intermittent claudication.

🚶 The term specifically refers to pain pattern rather than color change.

💉 When administering heparin subcutaneously, the nurse should avoid aspiration because aspiration can injure tissue and increase bruising.

💉 Heparin is an anticoagulant, so minimizing trauma at the injection site is especially important.

💉 The medication should be given in the abdomen using proper technique without rubbing or massaging afterward.

💉 Aspiration is not necessary for a subcutaneous heparin injection and can increase discomfort and hematoma formation.

💉 For this reason, the correct action is to avoid aspiration prior to injection.

Hold the drug and notify the health care provider if an INR has not been ordered

💉 INR monitoring is used for warfarin, not routine subcutaneous heparin administration.

💉 Heparin is more closely associated with aPTT monitoring when given intravenously.

Massage the injection site following the injection

💉 The injection site should not be massaged after heparin administration because massage can cause bruising and hematoma.

💉 This is especially dangerous because the drug reduces clotting ability.

Only use upper outer arm

💉 Heparin is commonly administered in the abdomen, not limited to the upper outer arm.

💉 Using the recommended abdominal subcutaneous tissue helps with safer absorption and technique.

🦠 A severely neutropenic client is placed in protective precautions because the client has very little ability to fight infection.

🦠 The purpose is to shield the client from microorganisms coming from outside sources, including visitors, staff, and contaminated items.

🦠 Neutropenia greatly increases the risk of serious infection from organisms that may be harmless to healthy people.

🦠 Protective precautions are designed to reduce the client’s exposure to potential pathogens in the environment.

🦠 Therefore, the best explanation is that the precautions help prevent the spread of organisms from outside the client’s environment.

“It will prevent the spread of organisms by using special techniques to handle the client's linens and personal items.”

🦠 Special handling of linens may be part of infection control, but this is not the main purpose of protective precautions.

🦠 The central goal is to protect the immunocompromised client from outside pathogens.

“It will prevent the spread of organisms by using special techniques to dispose of contaminated materials.”

🦠 Disposal of contaminated materials is part of general infection control, but it does not best explain why a neutropenic client needs protective precautions.

🦠 The emphasis is on preventing exposure of the client to infectious sources.

“It will prevent the spread of organisms from the client to health care personnel, visitors and other clients.”

🦠 This statement describes transmission-based isolation used to protect others from the client.

🦠 In neutropenia, the concern is the opposite: protecting the client from others.

🥬 Dark green vegetables and organ meats are rich sources of iron and are appropriate choices for a client who needs an iron-rich diet.

🥬 Iron is needed for the production of hemoglobin and healthy red blood cells.

🥬 Organ meats such as liver provide heme iron, which is absorbed well by the body.

🥬 Dark green vegetables also contribute iron and support treatment or prevention of iron deficiency.

🥬 For this reason, these foods should be included when teaching a client about iron-rich nutrition.

Cheeses and processed lunch meats

🥬 Cheese is not a rich source of iron, and processed lunch meats are not the best recommended iron-rich foods.

🥬 Processed meats may be high in sodium and are less appropriate than true iron-rich food sources.

Fruit juices and cornmeal breads

🥬 Fruit juices may contain vitamin C, which helps iron absorption, but they are not themselves major iron sources.

🥬 Cornmeal bread is also not considered a top iron-rich food choice in this context.

Fresh fruit and milk

🥬 Fresh fruit and milk are not strong sources of iron.

🥬 In fact, milk can interfere with adequate iron intake when it replaces more iron-rich foods.

🚨 A client with severe neutropenia is at extremely high risk for infection and progression to septic shock.

🚨 Indwelling urinary catheters are common sources of infection if aseptic technique is not carefully maintained.

🚨 Preventing the introduction of microorganisms is one of the most important nursing priorities in neutropenic care.

🚨 Strict asepsis helps reduce the risk of a catheter-associated urinary tract infection, which can quickly become systemic in an immunocompromised client.

🚨 For this reason, maintaining asepsis of indwelling urinary catheters is the most important intervention listed for preventing septic shock.

Monitoring red blood cell counts for elevation

🚨 Red blood cell counts are not the key indicator for preventing septic shock in a neutropenic client.

🚨 Infection prevention focuses more on avoiding pathogen exposure and monitoring for early signs of infection.

Obtaining vital signs every 4 hours for all clients

🚨 Monitoring vital signs is important, but the statement is too general and does not directly address the highest-priority infection-prevention measure for this neutropenic client.

🚨 Preventing infection entry through invasive devices is more specific and more critical here.

Administering intravenous (IV) fluid replacement therapy as ordered

🚨 IV fluid therapy may be needed in some situations, but it does not directly prevent septic shock from developing.

🚨 The more important nursing action is to prevent infection in the first place through strict aseptic care.