A nurse is caring for a client with liver cirrhosis. Which assessment finding supports the client's increased risk of hemorrhage?

Elevated platelet count.

Low prothrombin time (PT).

Decreased ammonia levels.

Elevated liver enzymes.

Answer and Explanation

The Correct Answer is A

A) Correct. In liver cirrhosis, the damaged liver may sequester platelets, leading to a decreased platelet count. However, an elevated platelet count (thrombocytosis) can occur as a compensatory response to decreased liver function and is a sign of an increased risk of hemorrhage due to poor clot formation.

B) Incorrect. Low prothrombin time (PT) indicates faster clotting and is not associated with an increased risk of hemorrhage.

C) Incorrect. Decreased ammonia levels are a positive finding in liver cirrhosis, as elevated ammonia levels are harmful to the brain.

D) Incorrect. Elevated liver enzymes are indicative of liver damage, but they do not directly impact the client's risk of hemorrhage.

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Correct Answer is A

Explanation

A) Correct. Before administering a blood transfusion, obtaining informed consent from the client is essential to ensure the client understands the procedure, its potential risks, and provides their voluntary agreement for the transfusion.

B) Incorrect. While pain assessment is important, it is not the most crucial action before starting a blood transfusion.

C) Incorrect. Prophylactic antibiotics are not typically administered before a blood transfusion unless specifically indicated for the client's condition.

D) Incorrect. While taking vital signs is important, obtaining consent is more critical before starting a blood transfusion.

A. The client has a history of hypertension. B. The client has been taking anticoagulant medication. C. The client is a regular blood donor. D. The client has a balanced diet.

Correct Answer is B

Explanation

A) Incorrect. While hypertension can be a risk factor for cardiovascular issues, it is not directly associated with an increased risk of hemorrhage.

B) Correct. Anticoagulant medication can interfere with the body's clotting mechanisms, making the client more susceptible to bleeding and hemorrhage.

C) Incorrect. Being a regular blood donor does not inherently increase the risk of hemorrhage unless the client donates too frequently, leading to anemia.

D) Incorrect. Having a balanced diet is essential for overall health, but it is not a specific risk factor for hemorrhage.

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A nurse is caring for a client with liver cirrhosis. Which assessment finding supports the client's increased risk of hemorrhage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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