When the nurse records a platelet count of 20,000/mm3, the most appropriate nursing action is to
a. encourage iron-rich foods.
b. increase fluid intake.
c. institute bleeding precautions.
d. place the client in protective isolation.
C
Teach the client and significant others to institute bleeding precautions during periods of throm-bocytopenia. Bleeding precautions include: soft toothbrushes and non-alcoholic rinses, no floss-ing, no nose-blowing or picking, administering stool softeners, not allowing women to douche or use tampons, using only electric razors, no injections, nothing in the rectum, no aspirin-containing compounds, avoiding urinary catheters, gentle suctioning if needed, removing sharp objects from the room and padding furniture, placing a pressure-reducing mattress on the bed, using care with the blood pressure cuff, and only using paper tape.
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Mechanical forces that interfere with normal prenatal development include oligohydramnios and fibrous amniotic bands. A patient at 34 weeks of gestation has reported to the OB triage unit for assessment of oligohydramnios
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The nurse wants to know if the nursing plan of care is effective for a male patient with malnutri-tion. Which assessment finding indicates to the nurse that the plan is effective?
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A) 20 B) 30 C) 40 D) 50