Nokea
The nurse reinforces education for a client who is diagnosed with a coagulopathy. Which client statement indicates a correct understanding of the definition for this disorder?
- A. My diagnosis means that I am missing or lacking components needed to control bleeding.
- B. My diagnosis is a bleeding disorder caused by a deficiency of globulins in my blood.
- C. My diagnosis is a bleeding disorder that involves red blood cells.
- D. My diagnosis means that I am at risk for developing blood clots.
Correct Answer: A
Rationale: The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate. Two common examples are thrombocytopenia and hemophilia. Coagulopathies do not involve red blood cells, nor are they characterized by a deficiency of globulins in the plasma.
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The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit?
- A. Excessive consumption of coffee or tea
- B. Elimination of iron by the body
- C. Decrease in the total body iron stores with age
- D. Blood loss from the gastrointestinal or genitourinary tract
Correct Answer: D
Rationale: If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is suspected. This is because iron-deficiency anemia is unusual in older adults as the body does not eliminate excessive iron, causing total body iron stores to increase with age. Excessive consumption of coffee or tea is not a causative factor for anemia in older adults.
A teenaged client with hemophilia sustains a leg laceration after falling off a skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be prescribed for administration to control bleeding?
- A. Fresh frozen plasma
- B. A colloid solution such as hetastarch (Hespan)
- C. A crystalloid solution such as lactated Ringer's
- D. Albumin
Correct Answer: A
Rationale: Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Other measures used to help control bleeding are the administration of fresh frozen plasma, aminocaproic acid that helps to hold a clot in place once it has formed, direct pressure over the bleeding site, and cold compresses or ice packs. Hetastarch, lactated Ringer's, or albumin will not control the bleeding related to hemophilia.
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?
- A. Inform the client that the position must be changed, and then you will give her pain medication and omit the bath.
- B. Inform the client that she will feel better after receiving a bath and clean sheets.
- C. Obtain the pain medication and delay the bath and position change until the medication reaches its peak.
- D. Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration.
Correct Answer: C
Rationale: When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.
A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
- A. Administer blood.
- B. Notify the physician.
- C. Insert two large-bore intravenous catheters.
- D. Administer a colloid solution.
Correct Answer: B
Rationale: A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's prescription and may not be required at this time.
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?
- A. Trauma and microabrasions from a non-electric razor may contribute to anemia.
- B. Strong tissues and intact clotting mechanisms may prevent hemorrhage.
- C. The client is at risk for spontaneous and uncontrolled bleeding.
- D. The client is not at risk for infection from microorganisms.
Correct Answer: A
Rationale: In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.