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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. While hypertension can be a risk factor for cardiovascular issues, it is not directly associated with an increased risk of hemorrhage.
B) Correct. Anticoagulant medication can interfere with the body's clotting mechanisms, making the client more susceptible to bleeding and hemorrhage.
C) Incorrect. Being a regular blood donor does not inherently increase the risk of hemorrhage unless the client donates too frequently, leading to anemia.
D) Incorrect. Having a balanced diet is essential for overall health, but it is not a specific risk factor for hemorrhage.
Correct Answer is C
Explanation
A) Incorrect. Administering oxygen is essential for a client experiencing difficulty breathing, but the nurse's immediate action should be to stop the blood transfusion and notify the healthcare provider.
B) Incorrect. While assessing the client's vital signs is important, the priority action is to stop the blood transfusion and seek immediate medical assistance.
C) Correct. Sudden difficulty breathing and chest pain after a blood transfusion may indicate an allergic reaction or transfusion-related acute lung injury (TRALI). The nurse should stop the transfusion immediately and inform the healthcare provider.
D) Incorrect. Elevating the head of the client's bed may be helpful in managing respiratory distress, but it is not the priority when there is a potential adverse reaction to the blood transfusion.
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