A nurse is caring for a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

Only use a soft-bristle toothbrush

Apply an ice pack over a bleeding wound

Use a Boss pick instead of the four string to floss in between the teeth

Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues

Answer and Explanation

The Correct Answer is A

A. Only use a soft-bristle toothbrush: Clients with thrombocytopenia are at risk for bleeding, including gum bleeding. Using a soft-bristle toothbrush minimizes trauma to the gums and reduces the risk of bleeding.

B. Apply an ice pack over a bleeding wound: While ice can help constrict blood vessels and reduce minor bleeding, it is not the primary preventative measure for thrombocytopenia-related bleeding.

C. Use a floss pick instead of the floss string to clean between teeth: A floss pick may still cause gum trauma. It is recommended to use a soft flossing technique or avoid flossing if platelet counts are extremely low.

D. Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues: While monitoring for petechiae or bruising is important, it does not actively prevent bleeding complications.

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Correct Answer is C

Explanation

A. Notify the health care provider: While notifying the provider is important, assessing the client comes first to determine if there is active bleeding.

B. Administer a 1-liter bolus of normal saline: Fluid resuscitation is used for shock, but the cause of symptoms must be assessed first.

C. Inspect the biopsy site dressing: The most concerning complication after a liver biopsy is internal bleeding, as the liver is highly vascular. Pallor and near-syncope may indicate hemorrhage. The priority action is to assess the biopsy site for bleeding before taking further action.

D. Position the client on the right side: Clients are typically positioned on the right side after a liver biopsy to apply pressure and reduce bleeding risk, but since the client is already experiencing symptoms of hypovolemia, assessment and intervention for potential hemorrhage take precedence.

A. Stoma coding red drainage B. Rosebud-like stoma orifice C. Purplish colored stoma D. Shiny, moist stoma

Correct Answer is C

Explanation

A. Stoma oozing red drainage: Some drainage is expected postoperatively.

B. Rosebud-like stoma orifice: This is a normal appearance of a healthy stoma.

C. Purplish colored stoma: A purplish stoma indicates ischemia or poor perfusion and requires immediate intervention.

D. Shiny, moist stoma: This is a normal finding for a stoma.

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A nurse is caring for a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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