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    Hesi PN Exit Proctored Exam Three

    A female client with immune thrombocytopenic purpura (ITP) is transferred to a long-term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

    Explanation & Rationale

    Immune thrombocytopenic purpura (ITP) is a condition characterized by low platelet levels in the blood, which can lead to an increased risk of bleeding and bruising. Patients with ITP are at risk of spontaneous bleeding, and any injury can be potentially serious. Ensuring the client has minimal clutter in the room is essential to reduce the risk of accidental falls and injuries. Falls and bumps can lead to bruising or bleeding, which can be particularly problematic in individuals with low platelet counts. Incorrect: A. Assessing the client for nerve pain or paralysis is important in the overall care of the patient, but it may not directly address the prevention of injury in this situation. C. Evaluating the client's neurological status after exercising is also essential for assessing their overall health and well-being but may not directly prevent injury. D. Monitoring the client's blood cell laboratory values, including platelet levels, is crucial for managing ITP, adjusting treatment if needed, and ensuring the client's condition remains stable. However, while important, this action is not directly related to preventing immediate injury in the care facility.

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