When evaluating a client’s rectal bleeding, which findings should the nurse document?

Number of blood clots expelled with each stool.

Unique odor noted with gastrointestinal bleeding.

Color characteristics of each stool.

Evidence of internal hemorrhoids.

Answer and Explanation

The Correct Answer is C

A. Number of blood clots expelled with each stool. This is not the most comprehensive approach as it focuses solely on clots without addressing other key aspects, such as stool color or consistency. Clots are also not always present with rectal bleeding.

B. Unique odor noted with gastrointestinal bleeding. While gastrointestinal bleeding, particularly upper GI bleeding, can produce a distinct odor, odor is subjective and not a reliable or standard assessment criterion to document.

C. Color characteristics of each stool. Stool color provides critical information about the source of the bleeding. For example, bright red blood (hematochezia) indicates lower GI bleeding, while black, tarry stools (melena) suggest upper GI bleeding. Documenting stool color helps in identifying the location and nature of the bleeding.

D. Evidence of internal hemorrhoids. While hemorrhoids are a common cause of rectal bleeding, the nurse cannot confirm the presence of internal hemorrhoids without diagnostic tools like anoscopy or sigmoidoscopy. The nurse should focus on documenting observable and measurable findings.

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Correct Answer is C

Explanation

Choice A rationale
Hypotonic tone of the anal sphincter is an abnormal finding and may indicate neurological or muscular disorders affecting the sphincter control.
Choice B rationale
A dimpled area above the anus can be a sign of a congenital condition such as a pilonidal sinus or other abnormalities.
Choice C rationale
Increased pigmentation and coarse skin around the anus are normal findings and are due to the natural variation in skin texture and color in this area.
Choice D rationale
A flap of tissue at the sphincter, also known as a skin tag, can be a normal finding but may also indicate previous hemorrhoids or other conditions.

A. White blood cell count (WBC). B. Blood urea nitrogen (BUN). C. Hematocrit. D. Glucose.

Correct Answer is C

Explanation

Choice A rationale
White blood cell count (WBC) is typically monitored to assess for signs of infection or inflammation. While it’s important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection.
Choice B rationale
Blood urea nitrogen (BUN) levels can be elevated in cases of gastrointestinal bleeding due to the breakdown of blood proteins in the gut. However, BUN is not the primary test to monitor in response to melena.
Choice C rationale
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information about the client’s red blood cell volume and can indicate the extent of blood loss.
Choice D rationale
Glucose levels are not directly related to melena. Monitoring glucose levels is essential for managing diabetes and other metabolic conditions but is not relevant to assessing the impact of gastrointestinal bleeding.

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When evaluating a client’s rectal bleeding, which findings should the nurse document?

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Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Correct Answer is C

Explanation

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is C

Explanation

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