A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?
A. Observe for evidence of spontaneous bleeding.
B. Limit visitors to family only.
C. Give aspirin in case of headaches.
D. Impose immune precautions.
Correct Answer: A. Observe for evidence of spontaneous bleeding.
Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising, particularly in the extremities. When the count falls below 15,000, spontaneous bleeding into the brain and internal organs may occur. Headaches may be a sign and should be watched for.
Options B and D: Thrombocytopenia does not compromise immunity, and there is no reason to limit visitors as long as any physical trauma is prevented.
Option C: Aspirin disables platelets and should never be used in the presence of thrombocytopenia.