A nurse is caring for a client who experienced external bleeding from a leg wound. Which finding should the nurse recognize as a potential sign of internal bleeding?

Swelling and bruising around the wound.

Cool and pale skin in the extremities.

Blood oozing from the wound site.

Visible blood clot formation.

Answer and Explanation

The Correct Answer is B

A) Incorrect. Swelling and bruising around the wound are common signs of external bleeding and do not directly indicate internal bleeding.

B) Correct. Cool and pale skin in the extremities may be indicative of vasoconstriction and reduced blood flow, which can occur in response to internal bleeding.

C) Incorrect. Blood oozing from the wound site is a typical sign of external bleeding and does not necessarily indicate internal bleeding.

D) Incorrect. Visible blood clot formation at the wound site is a normal part of the body's hemostatic response to control external bleeding and does not directly suggest internal bleeding.

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Correct Answer is B

Explanation

A) Incorrect. While pain management is important, it is not the priority in the management of massive hemorrhage and hypovolemia.

B) Correct. The priority intervention for a client experiencing massive hemorrhage and hypovolemia is to initiate a blood transfusion to replace lost blood and improve oxygen-carrying capacity.

C) Incorrect. Emotional support is essential, but it is not the priority in the acute management of hemorrhage and hypovolemia.

D) Incorrect. Deep breathing exercises are not the priority when the client is experiencing massive hemorrhage and requires urgent interventions to stabilize their condition.

A. Administer low-dose aspirin as prescribed. B. Encourage the client to participate in contact sports. C. Use a soft-bristled toothbrush for oral care. D. Monitor platelet levels daily.

Correct Answer is C

Explanation

A) Incorrect. Aspirin is an antiplatelet medication and can increase the risk of bleeding, so it should be avoided in clients at risk of hemorrhage.

B) Incorrect. Encouraging the client to participate in contact sports can increase the risk of trauma and bleeding, and it is not a preventive action.

C) Correct. Using a soft-bristled toothbrush for oral care can prevent gum and oral tissue injury, reducing the risk of bleeding in vulnerable clients.

D) Incorrect. Monitoring platelet levels daily is not a preventive action but a method of assessing the client's clotting status.

Questions

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A nurse is caring for a client who experienced external bleeding from a leg wound. Which finding should the nurse recognize as a potential sign of internal bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing massive hemorrhage. Which intervention should the nurse prioritize to address hypovolemia?

Correct Answer is B

Explanation

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

Correct Answer is C

Explanation

A nurse is caring for a client with suspected internal bleeding. Which diagnostic test should the nurse anticipate as a priority to confirm the presence of bleeding?

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?

A nurse is caring for a client with suspected hemorrhage. The nurse should anticipate which diagnostic test as a priority to identify the cause and source of bleeding?

A client is receiving anticoagulant therapy to prevent blood clots. Which statement by the client indicates a need for further education about the medication?

A nurse is caring for a client diagnosed with disseminated intravascular coagulation (DIC). What should the nurse recognize as the underlying mechanism of DIC?

A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

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?

A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention should the nurse prioritize during the initial resuscitation phase?