In caring for the patient who has a coagulopathy, what should the nurse do? (Select all that apply.)
take temperatures rectal to increase accuracy.
assess fluids for occult blood
weigh dressing to assess blood loss.
observe for oozing and bleeding and remove clots that form
limit invasive procedures.
Correct Answer : B,C,E
Rationale:
A. Take temperatures rectal to increase accuracy is incorrect because rectal temperatures can cause trauma and bleeding in patients with coagulopathy. Non-invasive methods, such as oral, axillary, or tympanic temperatures, are preferred to minimize the risk of bleeding.
B. Assess fluids for occult blood is correct because patients with coagulopathy are at high risk for internal bleeding, which may not be immediately visible. Testing for occult blood in urine or stool allows for early detection of gastrointestinal or urinary tract bleeding.
C. Weigh dressing to assess blood loss is correct because accurate measurement of blood loss is essential in patients with bleeding disorders. Weighing dressings provides objective data on the amount of blood lost, which guides fluid replacement, transfusions, and treatment decisions.
D. Observe for oozing and bleeding and remove clots that form is incorrect because removing clots can worsen bleeding. The nurse should observe clots and allow them to stabilize while monitoring for excessive bleeding.
E. Limit invasive procedures is correct because minimizing invasive procedures reduces the risk of bleeding. Any necessary procedures should be performed carefully with appropriate preparation and monitoring, including applying pressure and using hemostatic techniques as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Should suggest that the patient receive epidural analgesia is incorrect because epidural analgesia is not the standard or first-line approach for pain management in acute pancreatitis. Pain is typically managed pharmacologically with systemic analgesics, usually opioids, rather than invasive regional anesthesia techniques.
B. Provides IV push analgesics as needed is incorrect because PRN dosing can lead to peaks and troughs in pain control. Waiting for pain to become severe before administering medication can increase stress, worsen pancreatic stimulation, and make pain more difficult to control.
C. Administers pain medication on a routine schedule is correct because scheduled analgesia maintains consistent pain relief, prevents pain escalation, reduces physiologic stress, and helps limit pancreatic stimulation. Continuous pain control is essential in acute pancreatitis to promote comfort and healing.
D. Provides oral pain medication on an “as needed” (PRN) basis is incorrect because patients with acute pancreatitis are often NPO and may not tolerate oral medications. Additionally, PRN oral dosing does not provide consistent pain control and is inadequate for severe pancreatic pain.
Correct Answer is B
Explanation
Rationale:
A. Elevating the head of the bed to 10 degrees is incorrect because 10 degrees is usually insufficient to promote optimal venous drainage from the brain. Keeping the head in a natural (turned) position can also impair venous return, potentially increasing ICP.
B. Elevating the head of the bed to 30 degrees with the head in a neutral midline position is correct. This position promotes venous drainage from the brain, reduces intracranial pressure, and maintains cerebral perfusion. Neutral alignment prevents kinking of the jugular veins, which could impede venous outflow. Elevating the head too much (>45 degrees) can decrease cerebral perfusion, while flat positioning can worsen ICP.
C. Keeping the head of the bed flat, even with the head in a neutral midline position, is incorrect because flat positioning increases venous congestion in the brain, which can raise ICP.
D. Keeping the head of the bed flat with the head in a natural (turned) position is incorrect for the same reason as C and adds risk of impaired venous drainage due to rotation of the neck, which can further elevate ICP.
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