A nurse is caring for a client who experienced external bleeding from a leg wound. Which finding should the nurse recognize as a potential sign of internal bleeding?

Swelling and bruising around the wound.

Cool and pale skin in the extremities.

Blood oozing from the wound site.

Visible blood clot formation.

Answer and Explanation

The Correct Answer is B

A) Incorrect. Swelling and bruising around the wound are common signs of external bleeding and do not directly indicate internal bleeding.

B) Correct. Cool and pale skin in the extremities may be indicative of vasoconstriction and reduced blood flow, which can occur in response to internal bleeding.

C) Incorrect. Blood oozing from the wound site is a typical sign of external bleeding and does not necessarily indicate internal bleeding.

D) Incorrect. Visible blood clot formation at the wound site is a normal part of the body's hemostatic response to control external bleeding and does not directly suggest internal bleeding.

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Correct Answer is D

Explanation

A) Incorrect. Hemoglobin levels may initially be normal or slightly decreased, but they would decrease later due to the body's compensatory response to dilute the remaining blood.

B) Incorrect. Platelet count may not be significantly affected in the early stages of hemorrhage. It is mainly responsible for clot formation, which becomes more relevant in the later stages.

C) Incorrect. In the early stages of hemorrhage, the white blood cell count is not significantly affected. It plays a role in fighting infection and inflammation.

D) Correct. Hematocrit levels represent the proportion of red blood cells in the blood. During early stages of hemorrhage, there is a loss of red blood cells, leading to decreased hematocrit levels.

A. "The doctor will remove a sample of my bone marrow for testing." B. "They will use a scope to look inside my stomach and intestines." C. "The nurse will check my blood pressure and heart rate during the procedure." D. "They will perform an ultrasound to see if there's any bleeding in my abdomen."

Correct Answer is A

Explanation

A) Correct. Bone marrow aspiration involves the removal of a small sample of bone marrow from the hip bone to assess the production of blood cells and identify potential causes of bleeding disorders.

B) Incorrect. The statement describes an esophagogastroduodenoscopy (EGD), which is not the procedure scheduled for this client.

C) Incorrect. Monitoring blood pressure and heart rate is essential during any procedure, but it is not specific to bone marrow aspiration.

D) Incorrect. An ultrasound is not relevant to a bone marrow aspiration procedure and is not used to assess bleeding disorders. It is typically used for imaging soft tissues and organs.

Questions

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A nurse is caring for a client who experienced external bleeding from a leg wound. Which finding should the nurse recognize as a potential sign of internal bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has experienced a significant blood loss due to trauma. Which laboratory result should a nurse expect in the early stages of hemorrhage?

Correct Answer is D

Explanation

A client with suspected bleeding disorders is scheduled for a bone marrow aspiration. Which statement made by the client indicates a correct understanding of the procedure?

Correct Answer is A

Explanation

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