In caring for the patient who has a coagulopathy, what should the nurse do? (Select all that apply.)
Explanation & Rationale
Rationale: A. Take temperatures rectal to increase accuracy is incorrect because rectal temperatures can cause trauma and bleeding in patients with coagulopathy. Non-invasive methods, such as oral, axillary, or tympanic temperatures, are preferred to minimize the risk of bleeding. B. Assess fluids for occult blood is correct because patients with coagulopathy are at high risk for internal bleeding, which may not be immediately visible. Testing for occult blood in urine or stool allows for early detection of gastrointestinal or urinary tract bleeding. C. Weigh dressing to assess blood loss is correct because accurate measurement of blood loss is essential in patients with bleeding disorders. Weighing dressings provides objective data on the amount of blood lost, which guides fluid replacement, transfusions, and treatment decisions. D. Observe for oozing and bleeding and remove clots that form is incorrect because removing clots can worsen bleeding. The nurse should observe clots and allow them to stabilize while monitoring for excessive bleeding. E. Limit invasive procedures is correct because minimizing invasive procedures reduces the risk of bleeding. Any necessary procedures should be performed carefully with appropriate preparation and monitoring, including applying pressure and using hemostatic techniques as needed.