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 A
Explanation
A) Correct. A CT scan is a valuable diagnostic tool to identify the cause and source of bleeding, especially in cases of significant hemorrhage.
B) Incorrect. While a complete blood count (CBC) provides valuable information about the client's red blood cells and hemoglobin levels, it does not directly identify the cause and source of bleeding.
C) Incorrect. An electrocardiogram (ECG) is used to assess the heart's electrical activity and is not relevant to identifying the cause and source of bleeding.
D) Incorrect. Magnetic Resonance Imaging (MRI) is helpful in diagnosing various conditions but is not the primary test for identifying the cause and source of bleeding in a client with suspected hemorrhage.
Questions
Correct Answer is A
Explanation
A) Correct. Dizziness and lightheadedness are common signs of decreased blood flow, indicating a potential worsening of internal bleeding. Immediate intervention is required to prevent further complications.
B) Incorrect. While a slightly decreased blood pressure could be a concern, it may not be an immediate priority. The nurse should closely monitor the blood pressure and respond promptly if it drops significantly or trends downward.
C) Incorrect. Pale and cool skin may indicate poor perfusion, but it doesn't necessarily require immediate intervention unless it worsens or is accompanied by other alarming signs.
D) Incorrect. Although heart rate can be affected by hemorrhage, being within the normal range doesn't necessarily warrant immediate intervention. Other signs and symptoms should be considered as well.
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