A nurse is caring for a client with suspected internal bleeding. Which assessment finding requires immediate intervention?

Client reports feeling dizzy and lightheaded.

Client's blood pressure is slightly decreased.

Client's skin is pale and cool to the touch.

Client's heart rate is within the normal range.

Answer and Explanation

The Correct Answer is A

A) Correct. Dizziness and lightheadedness are common signs of decreased blood flow, indicating a potential worsening of internal bleeding. Immediate intervention is required to prevent further complications.

B) Incorrect. While a slightly decreased blood pressure could be a concern, it may not be an immediate priority. The nurse should closely monitor the blood pressure and respond promptly if it drops significantly or trends downward.

C) Incorrect. Pale and cool skin may indicate poor perfusion, but it doesn't necessarily require immediate intervention unless it worsens or is accompanied by other alarming signs.

D) Incorrect. Although heart rate can be affected by hemorrhage, being within the normal range doesn't necessarily warrant immediate intervention. Other signs and symptoms should be considered as well.

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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. Obtaining a written consent from the client. B. Assessing the client's level of pain. C. Administering prophylactic antibiotics. D. Taking the client's vital signs.

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.

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A nurse is caring for a client with suspected internal bleeding. Which assessment finding requires immediate intervention?

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 preparing to administer a blood transfusion to a client with hemorrhagic shock. Which action is essential before starting the transfusion?

Correct Answer is A

Explanation

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