When making morning rounds, a client with acute leukemia reports having nosebleeds off and on throughout the night. Which action should be taken by the nurse?
1. Check the client's blood pressure and pulse.
2. Determine whether client has pain anywhere.
3. Report the findings to the physician.
4. Apply a water-soluble lubricant to the nares.
Answer: 3
1. This should be done after notifying the physician.
2. This should be done after notifying the physician.
3. Manifestations of bleeding such as bleeding gums and nosebleeds should be reported promptly, since bleeding can lead to death in acute leukemia.
4. Lubricating the nares is not necessary.
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