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    NU335 proctored exam(adult healthmed surg exam (renal) exemplify

    The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient?

    Explanation & Rationale

    A. Maintenance of reverse isolation: Reverse isolation is used to protect immunocompromised patients from infection, not to prevent bleeding. While infection control is important, it does not directly address the primary pathophysiology of ITP, which is immune-mediated platelet destruction. B. Administration of packed red blood cells: Packed red blood cells are given to treat anemia, which may develop from significant bleeding, but this is a supportive measure rather than the primary treatment. It does not address the underlying immune-mediated platelet destruction. C. Administration of corticosteroids: Corticosteroids are first-line therapy for ITP because they suppress the immune system, reducing antibody-mediated platelet destruction. Early administration helps increase platelet count and reduce the risk of bleeding, directly targeting the pathophysiology of the disorder. D. Administration of clotting factors: ITP is characterized by low platelet count, not deficiencies in clotting factors. Administering clotting factors does not correct the primary problem of immune-mediated platelet destruction and is not indicated in standard ITP management.

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