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 ["1610"]

Explanation

Solution:

Convert ounces to milliliters (1 oz = 30 mL):
- Coffee: 8 oz × 30 mL = 240 mL
- Juice: 3 oz × 30 mL = 90 mL
- Soda: 12 oz × 30 mL = 360 mL
Calculate water intake:
- Initial pitcher: 800 mL
- Remaining: 200 mL
- Water intake = 800 mL - 200 mL = 600 mL
Calculate IV fluids intake:
- IV rate: 40 mL/hr
- Time: 8 hours
- IV fluids = 40 mL/hr × 8 hrs = 320 mL
Total intake:
- 240 mL (coffee) + 90 mL (juice) + 360 mL (soda) + 600 mL (water) + 320 mL (IV) = 1610 mL

Answer: 1610 mL

A. The spleen is the primary site for platelet destruction. B. The spleen is at risk for infection due to the critical loss of WBCs. C. Your spleen is making too many platelets. D. The spleen causes an overabundance of immature platelets.

Correct Answer is A

Explanation

A. The spleen is the primary site for platelet destruction. In ITP, the spleen often sequesters and destroys platelets, leading to low platelet levels. Removing the spleen reduces platelet destruction and can help increase platelet counts in affected patients.

B. The spleen is at risk for infection due to the critical loss of WBCs. While infection risk increases after splenectomy, this is not the rationale for the procedure. The spleen does play a role in immune function, but splenectomy is indicated for reducing platelet destruction, not infection prevention.

C. Your spleen is making too many platelets. The spleen does not produce platelets; rather, it filters and sometimes destroys them, particularly in ITP. This choice does not accurately reflect the pathophysiology of ITP.

D. The spleen causes an overabundance of immature platelets. The spleen does not cause an increase in immature platelets. In ITP, platelets are destroyed, not overproduced.

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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

Correct Answer is ["1610"]

Explanation

The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP). Which of the following statements best describes the rationale for the splenectomy?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?

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?

The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the following interventions is most important for the nurse to carry out before the procedure?

The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?

A nurse is reviewing laboratory findings for a client admitted with multiple myeloma. The nurse should expect to see an increase in which of the following laboratory tests?

A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?

The nurse is teaching the parent of a child with hemophilia. Which of the following statements by the parent demonstrates understanding about preventing bleeding episodes?

A nurse is collecting data from a client who has leukemia. Which of the following findings has the highest priority?