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) Correct. Anticoagulant medication can interfere with the body's clotting mechanism, increasing the risk of bleeding.

B) Correct. A family history of bleeding disorders can be a risk factor for hemorrhage due to potential genetic predisposition.

C) Incorrect. Regular low-impact exercise is a positive lifestyle choice that helps maintain cardiovascular health and does not directly contribute to an increased risk of hemorrhage.

D) Correct. Recent major surgery can be a risk factor for hemorrhage due to potential surgical site bleeding or complications.

A. "The doctor will remove a sample of my bone marrow for testing." B. "They will use a scope to look inside my stomach and intestines." C. "The nurse will check my blood pressure and heart rate during the procedure." D. "They will perform an ultrasound to see if there's any bleeding in my abdomen."

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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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 educating a client about the risk factors for hemorrhage. Which statement made by the client requires further clarification?

Correct Answer is C

Explanation

A client with suspected bleeding disorders is scheduled for a bone marrow aspiration. Which statement made by the client indicates a correct understanding of the procedure?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results of a client with suspected hemorrhage. Which finding should the nurse expect to observe in a client experiencing acute blood loss?

A nurse is assessing a client who experienced a significant hemorrhage. Which clinical manifestation should the nurse expect to find during the early stages of hemorrhage?

A nurse is caring for a client who experienced a hemorrhage and received a blood transfusion. Which clinical manifestation should the nurse monitor to determine the effectiveness of the transfusion?

A client is admitted to the emergency department following a motor vehicle accident. The nurse is aware that the client is at increased risk for hemorrhage due to which factor?

A nurse is caring for a client who experienced a hemorrhage and received a blood transfusion. The client reports sudden difficulty breathing and chest pain. What is the nurse's immediate action?

A nurse is caring for a client with hemophilia. Which statement by the client indicates a correct understanding of the condition?

A client with hemophilia is admitted to the hospital with an acute joint bleed. What is the nurse's priority intervention for managing joint bleeding in this client?

A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention should the nurse prioritize during the initial resuscitation phase?