The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which priority action by the nurse is most appropriate at this time?

Have the patient take a number and stay in the waiting area.

Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.

Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room.

Palpate the suspected area of bleeding for tenderness and edema.

Answer and Explanation

The Correct Answer is B

A. Have the patient take a number and stay in the waiting area. Delaying care could lead to worsening of a potentially life-threatening bleeding episode. Hemophilia patients should be assessed promptly.

B. Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis. Hemophilia patients are at risk of internal bleeding, which may not always be visible externally. Rapid assessment is essential to prevent complications from internal bleeding.

C. Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room. X-rays may not immediately detect bleeding in soft tissues. The physician should evaluate the patient first.

D. Palpate the suspected area of bleeding for tenderness and edema. Palpating could worsen bleeding or cause pain, and the nurse should focus on ensuring the patient is seen promptly by the physician.

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Correct Answer is D

Explanation

A. Hematocrit 35% (F 37%–47%; M 42%–52%): Although the hematocrit is slightly low, it is not as concerning as a low platelet count, which poses an immediate risk for bleeding.

B. Bone pain: Bone pain is common in leukemia due to bone marrow expansion, but it does not take priority over the risk of bleeding from thrombocytopenia.

C. Weight loss: Weight loss may be a symptom of leukemia, but it is not immediately life-threatening and does not take priority over a low platelet count that increases bleeding risk.

D. Platelet count 125,000/mm³ (150,000–400,000): A low platelet count is concerning in leukemia patients because it increases the risk of bleeding. Monitoring for and preventing bleeding is a high priority due to thrombocytopenia associated with leukemia.

A. Activity intolerance related to tissue hypoxia B. Ineffective airway clearance related to dyspnea. C. Risk for infection related to reduction in white blood cells (WBCs) D. Chronic pain related to bone marrow dysfunction

Correct Answer is A

Explanation

A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.

B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.

C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.

D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.

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The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which priority action by the nurse is most appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has leukemia. Which of the following findings has the highest priority?

Correct Answer is D

Explanation

The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

Correct Answer is A

Explanation

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