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.
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 C
Explanation
A. Hip: While “hip” can sometimes colloquially refer to the iliac crest, it is not commonly used to describe the specific site for aspiration outside of the iliac crest.
B. Cervical spine: The cervical spine is not a site used for bone marrow aspiration due to its inaccessibility and proximity to critical structures.
C. Sternum: The sternum is a common site for bone marrow aspiration in adults as it provides direct access to the marrow.
D. Humerus: The humerus is generally not used for bone marrow aspirations as it does not provide as accessible or large an area for aspiration.
Correct Answer is A
Explanation
A. The spleen is the primary site for platelet destruction. In ITP, the spleen often sequesters and destroys platelets, leading to low platelet levels. Removing the spleen reduces platelet destruction and can help increase platelet counts in affected patients.
B. The spleen is at risk for infection due to the critical loss of WBCs. While infection risk increases after splenectomy, this is not the rationale for the procedure. The spleen does play a role in immune function, but splenectomy is indicated for reducing platelet destruction, not infection prevention.
C. Your spleen is making too many platelets. The spleen does not produce platelets; rather, it filters and sometimes destroys them, particularly in ITP. This choice does not accurately reflect the pathophysiology of ITP.
D. The spleen causes an overabundance of immature platelets. The spleen does not cause an increase in immature platelets. In ITP, platelets are destroyed, not overproduced.