A client with hemophilia is admitted to the hospital with an acute joint bleed. What is the nurse's priority intervention for managing joint bleeding in this client?
Apply a warm compress to the affected joint.
Administer prescribed clotting factor replacement therapy.
Elevate the affected joint to reduce swelling.
Encourage active range of motion exercises.
The Correct Answer is B
A) Incorrect. Applying a warm compress may promote vasodilation and increase bleeding in the joint. It is not recommended for managing joint bleeding in a client with hemophilia.
B) Correct. The priority intervention for managing joint bleeding in a client with hemophilia is to administer prescribed clotting factor replacement therapy to promote clot formation and stop the bleeding.
C) Incorrect. Elevating the affected joint can help reduce swelling, but it is not the priority intervention when the client is experiencing an acute joint bleed.
D) Incorrect. Encouraging active range of motion exercises can worsen joint bleeding and is contraindicated in a client with acute joint bleeding due to hemophilia.
Questions
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Related Questions
Correct Answer is C
Explanation
A) Incorrect. Gastric analysis is not commonly used to confirm the presence of blood in the stomach or identify the source of bleeding.
B) Incorrect. Abdominal ultrasound may be helpful in evaluating certain abdominal conditions but is not the primary test for diagnosing upper gastrointestinal bleeding.
C) Correct. Esophagogastroduodenoscopy (EGD) is a direct visualization procedure that uses a flexible endoscope to examine the esophagus, stomach, and duodenum. It allows for visualization of the source of bleeding and potential interventions like cauterization or sclerotherapy.
D) Incorrect. Stool culture is used to detect gastrointestinal infections but is not specific to diagnosing upper gastrointestinal bleeding.
Correct Answer is A
Explanation
A) Correct. Dizziness and lightheadedness are common signs of decreased blood flow, indicating a potential worsening of internal bleeding. Immediate intervention is required to prevent further complications.
B) Incorrect. While a slightly decreased blood pressure could be a concern, it may not be an immediate priority. The nurse should closely monitor the blood pressure and respond promptly if it drops significantly or trends downward.
C) Incorrect. Pale and cool skin may indicate poor perfusion, but it doesn't necessarily require immediate intervention unless it worsens or is accompanied by other alarming signs.
D) Incorrect. Although heart rate can be affected by hemorrhage, being within the normal range doesn't necessarily warrant immediate intervention. Other signs and symptoms should be considered as well.
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