Which nursing intervention is most appropriate to prevent injury in a patient with severe thrombocytopenia due to chemotherapy?

Appeared in: NCL (Northern Coalfields Limited)-NO

Explanation

Thrombocytopenia is a condition of low platelet count, which impairs the body's ability to form clots and stop bleeding.
The primary goal of nursing care is to prevent injury and subsequent bleeding.
Using a soft-bristled toothbrush minimizes trauma to the highly vascular gum tissue during oral hygiene, thereby preventing gingival bleeding.
This intervention is a standard component of 'bleeding precautions' for patients at risk.

Option B: The Trendelenburg position is not related to preventing bleeding in thrombocytopenia. It is used for managing hypotension but can dangerously increase intracranial pressure.
Option C: Intramuscular injections are contraindicated in severe thrombocytopenia because they can cause significant bleeding into the muscle, leading to a hematoma.
Option D: Encouraging vigorous nose blowing can easily rupture fragile nasal blood vessels, causing epistaxis (nosebleed), which can be difficult to control in a patient with a low platelet count.

Visual 1: Infographic: Signs of bleeding to monitor in a patient with thrombocytopenia, such as petechiae, purpura, and ecchymosis.
Visual 2: Diagram: A comparison of a hard-bristled toothbrush causing gum trauma versus a soft-bristled toothbrush cleaning gently.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing interventions for thrombocytopenia and bleeding precautions to guide bedside assessment, documentation, and the next nursing action.
Nurses play a critical role in implementing and teaching bleeding precautions to prevent life-threatening hemorrhage in patients with thrombocytopenia.
Constant monitoring for subtle signs of bleeding (like petechiae or oozing from IV sites) is a key nursing responsibility that allows for early intervention.
Patient and family education on these precautions is essential for safety both in the hospital and at home.

How to Approach the Question

First, identify the core concept of the question. The patient has 'severe thrombocytopenia,' which means the central problem is a high risk of bleeding.
The question asks for the 'most appropriate' intervention to 'prevent injury.' This means you are looking for a safety measure that reduces the risk of bleeding.
Evaluate each option based on this goal:
Does this action reduce the risk of trauma or bleeding?
Does this action increase the risk of trauma or bleeding?
Eliminate options that are either harmful or irrelevant. Administering IM injections and encouraging nose blowing are harmful as they can induce bleeding. The Trendelenburg position is irrelevant to preventing bleeding.

Concept Tested & Keywords

Concept Tested: Nursing interventions for thrombocytopenia and bleeding precautions.
Stem keywords: nursing intervention, prevent injury, severe thrombocytopenia, chemotherapy
Lead-in keywords: most appropriate
Clinical cues: The patient has severe thrombocytopenia, indicating a critical risk for bleeding.
Negative lead-in flag: false

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Practise the full NCL (Northern Coalfields Limited)-NO

Attempt every question from this paper in a timed mock, then review the full solution for each one.