A nurse is caring for a client who is experiencing active bleeding. What is the nurse's priority intervention?

Administer pain medication to alleviate discomfort.

Assist the client to a comfortable position in bed.

Apply direct pressure to the bleeding site.

Obtain a detailed health history from the client.

Answer and Explanation

The Correct Answer is C

A) Incorrect. While pain management is essential, it is not the priority when dealing with active bleeding that requires immediate intervention.

B) Incorrect. Positioning the client comfortably is important, but it is not the priority when there is active bleeding.

C) Correct. The priority intervention is to apply direct pressure to the bleeding site to control and reduce bleeding until further assessment and medical assistance can be obtained.

D) Incorrect. Obtaining a detailed health history is valuable for understanding the client's overall health, but it is not the priority when the client is actively bleeding and requires immediate intervention.

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Correct Answer is A

Explanation

A) Correct. The priority during the initial resuscitation phase of hypovolemic shock is to replace lost intravascular volume promptly. Administering IV fluids rapidly is crucial to improve tissue perfusion and blood pressure.

B) Incorrect. While administering supplemental oxygen is important for tissue oxygenation, it is not the primary intervention during the initial resuscitation phase.

C) Incorrect. Monitoring blood glucose levels is important for overall assessment but is not the priority during the initial resuscitation phase of hypovolemic shock.

D) Incorrect. Neurological assessments are essential but may not be the immediate priority during the initial resuscitation phase of hypovolemic shock.

A. Gastric analysis B. Abdominal ultrasound C. Esophagogastroduodenoscopy (EGD) D. Stool culture

Correct Answer is C

Explanation

A) Incorrect. Gastric analysis is not commonly used to confirm the presence of blood in the stomach or identify the source of bleeding.

B) Incorrect. Abdominal ultrasound may be helpful in evaluating certain abdominal conditions but is not the primary test for diagnosing upper gastrointestinal bleeding.

C) Correct. Esophagogastroduodenoscopy (EGD) is a direct visualization procedure that uses a flexible endoscope to examine the esophagus, stomach, and duodenum. It allows for visualization of the source of bleeding and potential interventions like cauterization or sclerotherapy.

D) Incorrect. Stool culture is used to detect gastrointestinal infections but is not specific to diagnosing upper gastrointestinal bleeding.

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A nurse is caring for a client who is experiencing active bleeding. What is the nurse's priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention should the nurse prioritize during the initial resuscitation phase?

Correct Answer is A

Explanation

A nurse is caring for a client with a suspected upper gastrointestinal bleed. Which diagnostic test should the nurse anticipate to confirm the presence of blood in the stomach and differentiate the source of bleeding?

Correct Answer is C

Explanation

A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?

A nurse is providing education to a group of pregnant clients about the risk factors for postpartum hemorrhage. Which client statement indicates a need for further clarification?

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A nurse is caring for a client who is at risk of hemorrhage. What action should the nurse take to prevent bleeding episodes?

A client with suspected bleeding disorders is scheduled for a bone marrow aspiration. Which statement made by the client indicates a correct understanding of the procedure?