A nurse is caring for a client who is at risk of hemorrhage. What action should the nurse take to prevent bleeding episodes?
Administer low-dose aspirin as prescribed.
Encourage the client to participate in contact sports.
Use a soft-bristled toothbrush for oral care.
Monitor platelet levels daily.
The Correct Answer is C
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.
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Correct Answer is D
Explanation
A) Incorrect. While the respiratory rate is an important vital sign to monitor, it does not directly indicate the effectiveness of a blood transfusion.
B) Incorrect. Blood pressure is a critical vital sign, but it is not specific to assessing the effectiveness of a blood transfusion.
C) Incorrect. Urinary output is essential for assessing kidney function and fluid balance, but it does not directly reflect the impact of a blood transfusion.
D) Correct. Monitoring the hemoglobin level is crucial to determine if the blood transfusion has been effective in increasing the client's red blood cell count and improving oxygen-carrying capacity.
Correct Answer is A
Explanation
A) Correct. Bone marrow aspiration involves the removal of a small sample of bone marrow from the hip bone to assess the production of blood cells and identify potential causes of bleeding disorders.
B) Incorrect. The statement describes an esophagogastroduodenoscopy (EGD), which is not the procedure scheduled for this client.
C) Incorrect. Monitoring blood pressure and heart rate is essential during any procedure, but it is not specific to bone marrow aspiration.
D) Incorrect. An ultrasound is not relevant to a bone marrow aspiration procedure and is not used to assess bleeding disorders. It is typically used for imaging soft tissues and organs.
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