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 heat to the knee.
The Correct Answer is C
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:
This action is appropriate to assess for gastrointestinal bleeding, which can be a concern in clients with hemophilia due to the risk of spontaneous bleeding. Monitoring for signs of internal bleeding is crucial.
Choice D reason:
Heat application is generally avoided in acute bleeding episodes, as it can increase blood flow and potentially worsen bleeding. Ice is preferred to reduce swelling and pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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 B
Explanation
Choice A reason: Taking this medication with 8 ounces of water is not necessary. Sublingual nitroglycerin tablets are designed to dissolve under the tongue and be absorbed quickly into the bloodstream. Drinking water may interfere with the absorption and effectiveness of the medication.
Choice B reason: Taking one tablet at the first indication of chest pain is the correct instruction. Sublingual nitroglycerin tablets are used to relieve anginal pain by dilating the coronary arteries and improving blood flow to the heart. The client should place one tablet under the tongue as soon as chest pain occurs and wait for it to dissolve.
Choice C reason: Taking one tablet every 15 minutes during an acute attack is not the correct instruction. Sublingual nitroglycerin tablets have a short duration of action and may not provide adequate relief for a prolonged anginal attack. The client should follow the rule of three: take one tablet every 5 minutes for up to three doses. If the pain is not relieved after three doses, the client should call 911 or seek emergency medical attention.
Choice D reason: Taking this medication after each meal and at bedtime is not the correct instruction. Sublingual nitroglycerin tablets are not used for the prevention of angina. They are only used for the treatment of acute anginal episodes. Taking this medication regularly may cause tolerance and reduce its effectiveness.
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