Reduction of Risk Potential Practice Question

Question

The nurse is caring for a client with abnormal labs and is focused on bleeding precautions scenario 3. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Avoid unnecessary sticks and monitor bruising, stools, and gums.
3. C. Delegate the clinical assessment and nursing judgment to assistive personnel.
4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

B. Avoid unnecessary sticks and monitor bruising, stools, and gums.

Explanation

The priority action for bleeding precautions is to avoid unnecessary sticks and monitor bruising, stools, and gums. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: medium
• Domain: Reduction of Risk Potential
• Objective: bleeding precautions

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