A nurse is educating a client about the risk factors for hemorrhage. Which statement made by the client requires further clarification?
"I take anticoagulant medication for a heart condition."
"I have a family history of bleeding disorders."
"I regularly engage in low-impact exercise to stay healthy."
"I recently underwent major abdominal surgery."
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Swelling and bruising around the wound are common signs of external bleeding and do not directly indicate internal bleeding.
B) Correct. Cool and pale skin in the extremities may be indicative of vasoconstriction and reduced blood flow, which can occur in response to internal bleeding.
C) Incorrect. Blood oozing from the wound site is a typical sign of external bleeding and does not necessarily indicate internal bleeding.
D) Incorrect. Visible blood clot formation at the wound site is a normal part of the body's hemostatic response to control external bleeding and does not directly suggest internal bleeding.
Correct Answer is C
Explanation
A) Incorrect. Administering oxygen is essential for a client experiencing difficulty breathing, but the nurse's immediate action should be to stop the blood transfusion and notify the healthcare provider.
B) Incorrect. While assessing the client's vital signs is important, the priority action is to stop the blood transfusion and seek immediate medical assistance.
C) Correct. Sudden difficulty breathing and chest pain after a blood transfusion may indicate an allergic reaction or transfusion-related acute lung injury (TRALI). The nurse should stop the transfusion immediately and inform the healthcare provider.
D) Incorrect. Elevating the head of the client's bed may be helpful in managing respiratory distress, but it is not the priority when there is a potential adverse reaction to the blood transfusion.
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