A nurse is caring for a client at risk of hemorrhage. What is the nurse's priority action to prevent bleeding complications?

Encourage the client to ambulate frequently.

Administer prophylactic antibiotics as prescribed.

Apply pressure dressings to potential bleeding sites.

Monitor the client's blood glucose levels.

Answer and Explanation

The Correct Answer is C

A) Incorrect. While ambulation is important for overall health, it is not the priority action to prevent bleeding complications.

B) Incorrect. Prophylactic antibiotics may be prescribed for specific medical conditions but are not the primary intervention to prevent hemorrhage.

C) Correct. Applying pressure dressings to potential bleeding sites is the priority action to prevent or control bleeding. It helps promote hemostasis and reduces the risk of excessive bleeding.

D) Incorrect. Monitoring blood glucose levels is important for clients with diabetes but is not directly related to preventing hemorrhage.

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Correct Answer is A

Explanation

A) Correct. In liver cirrhosis, the damaged liver may sequester platelets, leading to a decreased platelet count. However, an elevated platelet count (thrombocytosis) can occur as a compensatory response to decreased liver function and is a sign of an increased risk of hemorrhage due to poor clot formation.

B) Incorrect. Low prothrombin time (PT) indicates faster clotting and is not associated with an increased risk of hemorrhage.

C) Incorrect. Decreased ammonia levels are a positive finding in liver cirrhosis, as elevated ammonia levels are harmful to the brain.

D) Incorrect. Elevated liver enzymes are indicative of liver damage, but they do not directly impact the client's risk of hemorrhage.

A. "You can resume normal activities immediately." B. "Monitor for signs of infection at the transfusion site." C. "Avoid consuming citrus fruits and juices." D. "Expect dark-colored stools after the transfusion."

Correct Answer is B

Explanation

A) Incorrect. While resuming normal activities is important, the client should also be cautious and monitor for any complications after a blood transfusion.

B) Correct. Monitoring for signs of infection at the transfusion site is crucial to identify any potential complications such as infection or infiltration.

C) Incorrect. Consuming citrus fruits and juices is not contraindicated after a blood transfusion and does not directly impact post-transfusion care.

D) Incorrect. Dark-colored stools are not an expected outcome after a blood transfusion. It is important for the client to be aware of any unusual changes in stool color or other potential side effects.

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A nurse is caring for a client at risk of hemorrhage. What is the nurse's priority action to prevent bleeding complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with liver cirrhosis. Which assessment finding supports the client's increased risk of hemorrhage?

Correct Answer is A

Explanation

A nurse is providing discharge education to a client who experienced hemorrhage and received a blood transfusion. What should the nurse include in the client's education?

Correct Answer is B

Explanation

A client is receiving anticoagulant therapy to prevent blood clots. The nurse identifies a potential adverse effect of anticoagulation as:

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