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

Neurological assessment

Skin integrity assessment

Abdominal assessment

Respiratory assessment

Answer and Explanation

The Correct Answer is B

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.

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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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 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 caring for a client with suspected hemorrhage. Which diagnostic test should the nurse anticipate to identify the exact location and cause of bleeding?

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