A client is admitted with rectal bleeding and melena. Which action should the nurse take to assess the client for blood loss?

Observe the rectal area for bleeding hemorrhoids.

Review the client's hemoglobin and hematocrit.

Determine if the client has been constipated.

Obtain a stool specimen for occult blood.

Joints which are warm, red, swollen, and tender.

Answer and Explanation

The Correct Answer is B

Brief introduction:

Gastrointestinal hemorrhage involving melena indicates the digestion of blood from an upper source, such as a peptic ulcer or esophageal varices. Assessment focuses on quantifying hemodynamic stability and identifying occult or overt loss through serial laboratory monitoring to detect a significant drop in circulating volume or oxygen-carrying capacity.

Rationale:

A. Observing for hemorrhoids identifies a potential source of bright red rectal bleeding but does not quantify the volume of blood lost. Melena originates from higher in the digestive tract, meaning local rectal inspection will not provide information regarding the systemic impact of the bleeding.

B. Reviewing the hemoglobin and hematocrit levels provides a scientific measurement of the severity of blood loss. These values are the most accurate indicators of anemia and help determine the need for blood transfusions or aggressive fluid resuscitation to maintain vital organ perfusion.

C. Determining if the client has been constipated relates to bowel habits but is not a direct measure of acute blood loss. While straining can exacerbate hemorrhoidal bleeding, it does not assist the nurse in assessing the physiological status or the urgency of the client’s current hemorrhagic state.

D. Obtaining a specimen for occult blood is redundant when the client already presents with visible melena and rectal bleeding. Since the presence of blood is already clinically evident, this test does not provide additional data regarding the total volume of blood lost from the vascular system.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Brief introduction:

Ischemic stroke involves a sudden focal neurological deficit caused by an arterial occlusion, leading to cerebral tissue hypoxia. The pathophysiology centers on a salvageable penumbra surrounding the infarcted core; rapid restoration of blood flow via reperfusion therapy is essential within the narrow 3 to 4.5 hour window to prevent irreversible neuronal death and permanent disability.

Rationale:

A. Sequential pneumatic compression devices are vital for venous thromboembolism prophylaxis in immobile patients. However, while important for long-term care, they are a lower priority during the hyperacute phase where the immediate focus must be on diagnosing and treating the primary cerebrovascular event to salvage brain tissue.

B. Assessing swallowing and communication is a necessary component of stroke rehabilitation and safety. While identifying receptive aphasia explains the client's frustration and inability to follow commands, these assessments must follow the stabilization and initiation of time-sensitive treatments designed to reverse the underlying ischemia.

C. Establishing venous access and checking fibrinolytic eligibility is the highest priority for a client in the hyperacute stroke window. Rapid administration of tissue plasminogen activator (tPA) can dissolve clots and restore perfusion; therefore, the nurse must prepare for treatment immediately to maximize the chances of neurological recovery.

D. Placing a urinary catheter allows for the monitoring of fluid balance, which is important in managing systemic hemodynamics. Nevertheless, this is a supportive task that should not delay the emergency protocols for stroke, as every minute of delay results in the loss of millions of functional neurons.

Correct Answer is ["1"]

Explanation

Step 1:Identify total dose and final volume after reconstitution
1 mg drug in 1 mL solution

Step 2:Use the relationship
1 mg = 1 mL

Step 3:Determine required volume
Ordered dose = 1 mg = 1 mL

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A client is admitted with rectal bleeding and melena. Which action should the nurse take to assess the client for blood loss?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is ["1"]

Explanation

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