A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Choice A rationale Applying pressure to needlestick sites for only 1 minute is insufficient for a client with thrombocytopenia. Thrombocytopenia is characterized by a low platelet count, which impairs the body's ability to form clots and stop bleeding. Insufficient pressure can lead to prolonged bleeding, hematoma formation, or ecchymosis. Prolonged pressure, typically 5-10 minutes, is necessary to facilitate hemostasis. Normal platelet count ranges from 150,000 to 450,000 platelets/µL. Choice B rationale Monitoring for the presence of white blood cells (WBCs) in the urine is primarily indicative of a urinary tract infection or kidney inflammation. While overall health monitoring is important, this specific intervention does not directly address the primary complication of thrombocytopenia, which is an increased risk of bleeding. WBCs in urine are not a direct consequence of low platelet counts. Normal urine WBC count is typically 0-5 WBCs/HPF. Choice C rationale Assessing core temperatures using a rectal thermometer is contraindicated in clients with thrombocytopenia due to the risk of inducing trauma and bleeding. The rectal mucosa is delicate and highly vascular, making it susceptible to injury when a rectal thermometer is inserted. Alternative, less invasive methods for temperature assessment, such as oral, tympanic, or temporal artery routes, should be used to prevent iatrogenic bleeding. Choice D rationale Measuring abdominal girth twice weekly is an essential intervention for a client with thrombocytopenia. An increasing abdominal girth can indicate internal bleeding, such as a retroperitoneal hemorrhage or splenic rupture, which are serious complications of low platelet counts. Regular monitoring allows for early detection and intervention, preventing potentially life-threatening hemorrhagic events.