A nurse is caring for a client at risk of hemorrhage. What is the nurse's priority action to prevent bleeding complications?
Encourage the client to ambulate frequently.
Administer prophylactic antibiotics as prescribed.
Apply pressure dressings to potential bleeding sites.
Monitor the client's blood glucose levels.
The Correct Answer is C
A) Incorrect. While ambulation is important for overall health, it is not the priority action to prevent bleeding complications.
B) Incorrect. Prophylactic antibiotics may be prescribed for specific medical conditions but are not the primary intervention to prevent hemorrhage.
C) Correct. Applying pressure dressings to potential bleeding sites is the priority action to prevent or control bleeding. It helps promote hemostasis and reduces the risk of excessive bleeding.
D) Incorrect. Monitoring blood glucose levels is important for clients with diabetes but is not directly related to preventing hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. While pain management is important, it is not the priority in the management of massive hemorrhage and hypovolemia.
B) Correct. The priority intervention for a client experiencing massive hemorrhage and hypovolemia is to initiate a blood transfusion to replace lost blood and improve oxygen-carrying capacity.
C) Incorrect. Emotional support is essential, but it is not the priority in the acute management of hemorrhage and hypovolemia.
D) Incorrect. Deep breathing exercises are not the priority when the client is experiencing massive hemorrhage and requires urgent interventions to stabilize their condition.
Correct Answer is A
Explanation
A) Correct. Anticoagulant therapy prevents blood from clotting effectively, which can lead to an increased risk of bleeding.
B) Incorrect. Anticoagulant therapy is not associated with elevated blood pressure readings.
C) Incorrect. Hyperactivity and restlessness are not typical adverse effects of anticoagulant therapy.
D) Incorrect. Anticoagulant therapy does not increase blood viscosity (thickness); instead, it reduces the blood's ability to form clots.
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