Difficulty: Medium
Average Score: 74%
Simulated
The nurse is caring for a client receiving nasal cannula oxygen and prescribed warfarin for venous thromboembolism (VTE) prevention. The unlicensed assistive personnel (UAP) informs the nurse that the client has a nose bleed. The nurse should initially
Correct answer
C
Rationale
Assessing for bruising and bleeding gums (C) evaluates the extent of bleeding risk on warfarin. Applying jelly (A) is inappropriate, reviewing aPTT (B) is secondary, and humidifying oxygen (D) is not urgent.