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 C
Explanation
A. Hypertension is not an early sign of hemorrhage; instead, hypotension occurs as blood loss progresses.
B. Bradycardia is not an expected response; tachycardia is more common due to compensatory mechanisms.
C. Tachypnea is an early indicator of internal bleeding as the body attempts to compensate for decreased oxygen delivery by increasing respiratory rate.
D. Hyperthermia is not associated with hemorrhage; instead, hypothermia can occur with significant blood loss.
Correct Answer is B
Explanation
A) Incorrect. Acute blood loss does not typically lead to a decreased platelet count. Platelet levels may remain within the normal range or slightly decrease due to hemodilution.
B) Correct. In acute blood loss, the concentration of red blood cells decreases, leading to hemoconcentration and elevated hemoglobin levels. This is the body's initial response to conserve oxygen-carrying capacity.
C) Incorrect. An increased white blood cell count is not a direct result of acute blood loss and may indicate other inflammatory or infectious processes.
D) Incorrect. Elevated liver enzymes are not a typical finding in acute blood loss. They are more indicative of liver injury or dysfunction.
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