When checking laboratory values, the nurse notes the client's platelet count is 100,000 mm3. The nurse should include which of the following actions in the client's plan of care?
A)
Encourage client to increase ambulation to prevent a deep venous thrombosis.
B)
Instruct client to increase intake of vitamin C to assist in blood coagulation.
C)
Hold pressure over injection sites to ensure clotting has occurred.
D)
Use strict sterile technique with wound care in order to prevent infection.
C
Explanation:
A)
A platelet count of 100,000 is less than the norm of 150,000 to 450,000, putting client at risk of bleeding secondary to decreased clotting ability. Vitamin K, not C, is needed for clot formation. A reduced WBC increases risk of infection.
Analysis
Implementation
Physiological Integrity: Reduction of Risk Potential
B)
A platelet count of 100,000 is less than the norm of 150,000 to 450,000, putting client at risk of bleeding secondary to decreased clotting ability. Vitamin K, not C, is needed for clot formation. A reduced WBC increases risk of infection.
Analysis
Implementation
Physiological Integrity: Reduction of Risk Potential
C)
A platelet count of 100,000 is less than the norm of 150,000 to 450,000, putting client at risk of bleeding secondary to decreased clotting ability. Vitamin K, not C, is needed for clot formation. A reduced WBC increases risk of infection.
Analysis
Implementation
Physiological Integrity: Reduction of Risk Potential
D)
A platelet count of 100,000 is less than the norm of 150,000 to 450,000, putting client at risk of bleeding secondary to decreased clotting ability. Vitamin K, not C, is needed for clot formation. A reduced WBC increases risk of infection.
Analysis
Implementation
Physiological Integrity: Reduction of Risk Potential
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