A nurse is caring for a client who has hemophilia A and hemarthrosis of the left knee. Which of the following actions should the nurse take?
Administer low dose aspirin.
Prepare for autologous blood transfusion.
Obtain a stool specimen.
Apply ice to the knee.
None
None
The Correct Answer is D
The correct answer is: D. Apply heat to the knee.
Choice A reason:
Administering low dose aspirin is not appropriate for clients with hemophilia A because aspirin can inhibit platelet function and increase the risk of bleeding. Hemophilia A patients already have a deficiency in clotting factor VIII, and adding aspirin can exacerbate bleeding tendencies.
Choice B reason:
Preparing for an autologous blood transfusion is not a standard treatment for hemarthrosis in hemophilia A. The primary treatment involves factor replacement therapy to address the underlying clotting deficiency. Blood transfusions are generally reserved for severe cases of anemia or significant blood loss.
Choice C reason:
Obtaining a stool specimen is unnecessary because the client’s symptoms are localized to the knee rather than the gastrointestinal tract. This procedure is used to detect GI bleeding and does not address the acute hemarthrosis described. Focusing on a stool sample would delay the essential care needed to stop the joint hemorrhage. Priority must be placed on interventions that directly manage the active bleeding site.
Choice D reason:
Applying ice to the knee triggers vasoconstriction, which directly limits internal bleeding into the joint space. This action follows the RICE protocol to reduce inflammation and provide immediate pain relief. By cooling the area, the nurse helps stabilize the injury and prevents further swelling. It is a vital step in minimizing long-term damage to the joint's synovial tissue.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Eating a green salad every night with dinner is not the statement that indicates a need for further teaching. This is a consistent and balanced dietary choice for the client, as long as the amount of vitamin K in the salad is not excessive or variable. Vitamin K is a nutrient that helps the blood to clot and can interfere with the action of warfarin, which is an anticoagulant that inhibits the formation of blood clots. The client should avoid sudden changes in their intake of vitamin K and inform the provider of any dietary modifications.
Choice B reason: Taking this medication at the same time each day is not the statement that indicates a need for further teaching. This is a correct and important instruction for the client, as it helps to maintain a steady and effective level of warfarin in the blood. Warfarin has a narrow therapeutic range and requires frequent monitoring and dose adjustment. The client should take the medication as prescribed and avoid missing or skipping doses.
Choice C reason: Starting to take ginger root to treat joint stiffness is the statement that indicates a need for further teaching. This is a risky and potentially harmful herbal supplement for the client, as it can interact with warfarin and increase its anticoagulant effect. Ginger root has antiplatelet and fibrinolytic properties, which can inhibit the formation of blood clots and enhance the breakdown of fibrin, a protein that stabilizes blood clots. Taking ginger root with warfarin can increase the risk of bleeding and bruising and alter the international normalized ratio (INR), which is a measure of the blood's clotting ability. The client should avoid taking ginger root and other herbal supplements without consulting the provider.
Choice D reason: Having the INR checked three weeks ago is not the statement that indicates a need for further teaching. This is a reasonable and appropriate frequency for the client, depending on their stability and response to warfarin therapy. The INR is a blood test that measures the time it takes for the blood to clot and indicates the effectiveness of warfarin. The target INR range for most clients is 2 to 3, but it may vary depending on the indication and the risk of bleeding. The client should have their INR checked regularly and follow the provider's orders and the protocol for dose adjustment.
Correct Answer is D
Explanation
Choice A reason: "Place one tablet under your tongue every 5 minutes for 30 minutes to relieve chest pain." is not the correct statement. This is an incorrect and potentially dangerous instruction, as it can cause overdose and severe hypotension. The nurse should instruct the client to place one tablet under the tongue at the first sign of chest pain, and repeat every 5 minutes for up to three doses, if needed. The client should call 911 if the pain is not relieved after the first dose.
Choice B reason: "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." is not the correct statement. This is a false and misleading explanation of how nitroglycerin works. Nitroglycerin does not dissolve blood clots, nor does it affect the occlusion of the arteries. Nitroglycerin is a vasodilator that relaxes the smooth muscle of the blood vessels, especially the veins. This reduces the preload and the oxygen demand of the heart, and relieves the chest pain caused by ischemia.
Choice C reason: "You can store the bottle of tablets in your bathroom medicine cabinet." is not the correct statement. This is an inappropriate and unsafe storage recommendation, as it can affect the potency and effectiveness of the medication. The nurse should instruct the client to store the bottle of tablets in a cool, dry, and dark place, away from heat, moisture, and light. The client should also keep the bottle tightly closed and replace it every 6 months, or as directed by the provider.
Choice D reason: "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." is the correct statement. This is a simple and accurate description of how nitroglycerin helps to relieve anginal pain. Nitroglycerin dilates the coronary arteries, which supply blood and oxygen to the heart muscle. This improves the blood flow and oxygen delivery to the ischemic areas of the heart, and reduces the pain and discomfort.
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