The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which priority action by the nurse is most appropriate at this time?

Have the patient take a number and stay in the waiting area.

Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.

Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room.

Palpate the suspected area of bleeding for tenderness and edema.

Answer and Explanation

The Correct Answer is B

A. Have the patient take a number and stay in the waiting area. Delaying care could lead to worsening of a potentially life-threatening bleeding episode. Hemophilia patients should be assessed promptly.

B. Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis. Hemophilia patients are at risk of internal bleeding, which may not always be visible externally. Rapid assessment is essential to prevent complications from internal bleeding.

C. Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room. X-rays may not immediately detect bleeding in soft tissues. The physician should evaluate the patient first.

D. Palpate the suspected area of bleeding for tenderness and edema. Palpating could worsen bleeding or cause pain, and the nurse should focus on ensuring the patient is seen promptly by the physician.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The patient should increase intake of fluids. Increased fluid intake helps flush excess calcium from the kidneys, which is vital for patients with hypercalcemia, a common complication of multiple myeloma.

B. The patient should increase intake of fresh fruits. Fresh fruits can be healthy but do not directly reduce hypercalcemia risk. Fluid intake is more critical in preventing calcium build up.

C. The patient should decrease intake of red meat. While reducing red meat can be beneficial for overall health, it does not directly address hypercalcemia.

D. The patient should avoid alcoholic beverages. Avoiding alcohol is generally beneficial, but it is not specifically related to managing hypercalcemia in multiple myeloma.

A. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential.

Correct Answer is C

Explanation

A. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. A nebulizer is typically not the initial intervention for mild post-operative pain or mild respiratory discomfort due to pain with inspiration.

B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. While heat or cold therapy can help with pain, opioid pain management with encouragement to perform deep breathing exercises is more effective for post-splenectomy patients.

C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. Pain management combined with encouraging deep breathing, coughing, and early ambulation helps prevent post-operative complications like atelectasis and pneumonia, which are common after abdominal surgeries.

D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential. This intervention might be necessary if there were signs of infection or other complications, but mild pain with inspiration on the first day post-op does not typically warrant imaging or labs.

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The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which priority action by the nurse is most appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting the patient with multiple myeloma in arranging a meal plan to lower the risk of complications from hypercalcemia. Which of the following would be the MOST IMPORTANT component of the patient's intake?

Correct Answer is A

Explanation

The nurse is caring for the patient who is 1-day status post splenectomy. The patient complains of pain of a 3 on inspiration. What would be the most appropriate priority nursing intervention for this patient?

Correct Answer is C

Explanation

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The nurse is assessing a patient in a family practice clinic. The patient had extensive testing to rule out Hodgkin disease. Which of the following characteristics would indicate Hodgkin disease?

A nurse is assisting in planning care for a client who has advanced multiple myeloma. When planning care the nurse should recognize that the client is at risk for which of the following complications?

A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?