A client is receiving anticoagulant therapy to prevent blood clots. The nurse identifies a potential adverse effect of anticoagulation as:

Increased risk of bleeding.

Elevated blood pressure readings.

Hyperactivity and restlessness.

Increased blood viscosity.

Answer and Explanation

The Correct Answer is A

A) Correct. Anticoagulant therapy prevents blood from clotting effectively, which can lead to an increased risk of bleeding.

B) Incorrect. Anticoagulant therapy is not associated with elevated blood pressure readings.

C) Incorrect. Hyperactivity and restlessness are not typical adverse effects of anticoagulant therapy.

D) Incorrect. Anticoagulant therapy does not increase blood viscosity (thickness); instead, it reduces the blood's ability to form clots.

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Correct Answer is B

Explanation

A) Incorrect. A neurological assessment is important to evaluate the client's central nervous system function, but it is not directly related to identifying bleeding sources.

B) Correct. A skin integrity assessment is essential to identify potential external bleeding sources, such as cuts, bruises, or petechiae, which may indicate underlying bleeding disorders.

C) Incorrect. While an abdominal assessment is crucial in identifying internal bleeding in the abdominal area, it is not the most essential assessment to identify bleeding sources overall.

D) Incorrect. A respiratory assessment is important for assessing oxygenation and respiratory status, but it is not the primary assessment to identify bleeding sources.

Questions

A. "You can resume normal activities immediately." B. "Monitor for signs of infection at the transfusion site." C. "Avoid consuming citrus fruits and juices." D. "Expect dark-colored stools after the transfusion."

Correct Answer is B

Explanation

A) Incorrect. While resuming normal activities is important, the client should also be cautious and monitor for any complications after a blood transfusion.

B) Correct. Monitoring for signs of infection at the transfusion site is crucial to identify any potential complications such as infection or infiltration.

C) Incorrect. Consuming citrus fruits and juices is not contraindicated after a blood transfusion and does not directly impact post-transfusion care.

D) Incorrect. Dark-colored stools are not an expected outcome after a blood transfusion. It is important for the client to be aware of any unusual changes in stool color or other potential side effects.

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A client is receiving anticoagulant therapy to prevent blood clots. The nurse identifies a potential adverse effect of anticoagulation as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a suspected bleeding disorder. Which nursing assessment is most essential to identify potential bleeding sources?

Correct Answer is B

Explanation

A nurse is providing discharge education to a client who experienced hemorrhage and received a blood transfusion. What should the nurse include in the client's education?

Correct Answer is B

Explanation

A nurse is providing education to a group of pregnant clients about the risk factors for postpartum hemorrhage. Which client statement indicates a need for further clarification?

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A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?

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A nurse is caring for a client who is at risk of hemorrhage. What action should the nurse take to prevent bleeding episodes?

A nurse is assessing a client who experienced a significant hemorrhage. Which clinical manifestation should the nurse expect to find during the early stages of hemorrhage?