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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect. While a complete blood count (CBC) provides valuable information about the client's red blood cell count and hemoglobin levels, it does not directly confirm the presence of bleeding or assess the clotting function.
B) Incorrect. Magnetic Resonance Imaging (MRI) is a valuable tool for diagnosing various conditions but is not a primary test for confirming the presence of bleeding.
C) Correct. A coagulation panel, which includes prothrombin time (PT) and activated partial thromboplastin time (PTT), helps assess the clotting function and can aid in confirming the presence of bleeding and identifying coagulation disorders.
D) Incorrect. Fecal Occult Blood Test (FOBT) is used to detect hidden blood in stool, which is indicative of lower gastrointestinal bleeding, but it does not confirm internal bleeding in other areas of the body.
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.
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