NCLEX® Question of the Day: Hemophilia

The nurse is caring for a client who is at risk for bleeding related to complications of hemophilia. Which intervention is appropriate to delegate to the assistive personnel (AP)?

A. Obtaining a rectal temperature

C. Brush and floss the client’s teeth

D. Administering aspirin for pain

The correct answer to today's NCLEX-RN® Question is...

B. Shaving the client with an electric razor

Rationale: Clients who are at risk for bleeding must only be shaved with an electric razor and never a straight razor. Electric razors present less of a risk of creating lacerations and causing excessive bleeding. This is an appropriate task to delegate to an AP.

Major Takeaway

Care of clients with Risk for bleeding related to hemophilia should involve appropriate interventions. These include client education about bleeding risk, avoiding toothpicks or dental floss, avoiding tampons, rectal suppositories or rectal thermometers, limiting straining during bowel movements, and shaving only with an electric razor. The nurse should only delegate activities or tasks to an assistive personnel (AP) using the five rights of delegation: right task, right circumstance, right person, right supervision, and right direction and communication.

Incorrect answer explanations

A. Obtaining a rectal temperature

Rationale: Although this may be an appropriate action to delegate to an AP, rectal temperatures should be avoided in clients at high risk for bleeding. Doing so may cause trauma to the mucous membranes in the rectum and lead to bleeding.

C. Brush and floss the client’s teeth

Rationale: Although it is within the AP’s scope of practice to perform mouth care, clients who are at risk for bleeding should not have their teeth flossed. Flossing between the teeth presents a risk for bleeding due to the possibility of causing gingival damage and lacerations. 

D. Administering aspirin for pain

Rationale: This is not an appropriate task to delegate to an AP, as medication administration is outside of the AP’s scope. It is the responsibility of the nurse to perform medication administration. However, aspirin should be avoided in clients with hemophilia or at high risk for bleeding since it may increase bleeding risk. 

________________________

Want more NCLEX®-style practice questions? Try Osmosis today! Access your free trial and find out why millions of current and future clinicians and caregivers love learning with us.