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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Ataxia is not a manifestation of digoxin toxicity, as it does not affect the coordination or balance of the client. Ataxia may be caused by other factors, such as cerebellar disorders, alcohol intoxication, or medication interactions.
Choice B reason: Anorexia is a manifestation of digoxin toxicity, as it affects the appetite and digestion of the client. Anorexia may be accompanied by nausea, vomiting, or abdominal pain, which are also signs of digoxin toxicity. Anorexia may lead to weight loss, dehydration, or electrolyte imbalance, which can worsen the condition of the client.
Choice C reason: Photosensitivity is not a manifestation of digoxin toxicity, as it does not affect the skin or the eyes of the client. Photosensitivity may be caused by other factors, such as sun exposure, allergies, or medication interactions.
Choice D reason: Jaundice is not a manifestation of digoxin toxicity, as it does not affect the liver or the bilirubin level of the client. Jaundice may be caused by other factors, such as liver disease, gallstones, or hemolysis.
Correct Answer is D
Explanation
Choice A reason: Vomiting is not a specific sign of a hemolytic reaction, as it can be caused by many other factors, such as anesthesia, infection, or medication. Vomiting may occur in other types of transfusion reactions, such as allergic or febrile reactions, but it is not indicative of hemolysis.
Choice B reason: Flushing is not a specific sign of a hemolytic reaction, as it can be caused by many other factors, such as fever, infection, or medication. Flushing may occur in other types of transfusion reactions, such as allergic or febrile reactions, but it is not indicative of hemolysis.
Choice C reason: Dyspnea is often linked with transfusion-associated circulatory overload (TACO) or transfusion-related acute lung injury (TRALI). Both of these conditions primarily impact the respiratory system, leading to difficulty breathing. Although respiratory symptoms can accompany severe reactions, dyspnea is not a key feature of a hemolytic reaction.
Choice D reason: Hypotension is a significant indicator of an acute hemolytic reaction. When the recipient’s immune system attacks the donor red blood cells, widespread inflammatory and immune responses occur, leading to vascular collapse. This can manifest as sudden low blood pressure, which is life-threatening if not recognized and treated immediately. Alongside other findings such as fever, chills, flank pain, and hemoglobinuria, hypotension is a classic hallmark of hemolysis during transfusion.
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