The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that:
a. all patients with bleeding disorders demonstrate active bleeding.
b. many patients have bleeding that is not obvious.
c. mucous membranes have a high threshold for bleeding.
d. capillaries in mucous membranes lie deep in the membrane.
B
Although many patients with bleeding disorders demonstrate active bleeding from body orifices, mucous membranes, and open lesions or intravenous line sites, equal numbers of patients have less obvious bleeding. The most susceptible sites for bleeding are existing openings in the epithelial surfaces. Mucous membranes have a low threshold for bleeding because the capillaries lie close to the membrane surface, and minor injury may damage and expose vessels. Substantial blood loss can occur in any coagulopathy, resulting in hypovolemic shock.
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Why is it important for the nurse to be observant of patient behavior?
a. Behavior is preformed b. Behavior is important c. Behavior is learned d. Behavior is repeated
A patient who has undergone a femoral to popliteal bypass graft surgery returns to your unit. Which assessments should be performed during the first postoperative day?
A) Assess pulse of affected extremity every 15 minutes at first. B) Assess pulse of affected extremity every shift. C) Ensure the patient is crossing the legs. D) Perform Doppler evaluation every 4 hours.
At a community health fair, the nurse informs the residents that the influenza vaccine is recommended for which of the following clients?
a. Only clients who are older than 65 years b. Clients aged 40 to 60 years c. Clients in any age group who have a chronic disease d. Clients in any age group who are currently experiencing flu-like symptoms
The nurse is preparing to cleanse an older patient's pressure injury. Which techniques should the nurse use to perform this action? Select all that apply.
1. Pour saline over the wound using a saline-filled syringe. 2. Apply saline-soaked gauze over the wound. 3. Apply hydrogen peroxide over the wound. 4. Place gauze pads soaked with Dakin's solution on the wound. 5. Apply dry gauze pads over the wound and saturate with sterile water.