A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?
Obtain a complete blood count (CBC)
Start IV fluids
Apply direct pressure
Administer pain medication
The Correct Answer is C
A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.
B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.
C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.
D. Administer pain medication: Pain management is important but not the priority in acute bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sodium level: Serum sodium levels can vary and are not a direct measure of fluid retention.
B. Tissue edema: Edema is subjective and can be influenced by other conditions.
C. Urinary output: Many CKD patients have limited or no urine output despite fluid retention.
D. Daily weight: Daily weights are the most reliable non-invasive measure for fluid status.
Correct Answer is ["B","C","E"]
Explanation
A. Fluid volume deficit: This is an acute phase complication. After 12 months, the client is in the rehabilitation phase, and fluid balance is typically stabilized.
B. Symptoms of post-traumatic stress: PTSD is common after severe burn trauma, especially with long hospital stays or painful treatments.
C. Depression: Chronic physical and emotional stress, changes in appearance, and functional limitations contribute to depression.
D. Electrolyte imbalances: These are more likely during the acute and early recovery phase. At 12 months, electrolyte levels are usually normalized unless other complications exist.
E. Body image disorder: Disfigurement and scarring from severe burns often result in body image disturbances, which affect emotional well-being and social reintegration.
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