A nurse is caring for a client who is experiencing massive hemorrhage. Which intervention should the nurse prioritize to address hypovolemia?
Administering pain medication for comfort.
Initiating blood transfusion as prescribed.
Providing emotional support to the client.
Encouraging deep breathing exercises.
The Correct Answer is B
A) Incorrect. While pain management is important, it is not the priority in the management of massive hemorrhage and hypovolemia.
B) Correct. The priority intervention for a client experiencing massive hemorrhage and hypovolemia is to initiate a blood transfusion to replace lost blood and improve oxygen-carrying capacity.
C) Incorrect. Emotional support is essential, but it is not the priority in the acute management of hemorrhage and hypovolemia.
D) Incorrect. Deep breathing exercises are not the priority when the client is experiencing massive hemorrhage and requires urgent interventions to stabilize their condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Bradycardia is not typically an early sign of compensatory response to hypovolemia. The body often responds to hypovolemia with an increased heart rate (tachycardia).
B) Correct. In the early stages of hypovolemia, the body may attempt to compensate by increasing blood pressure to maintain perfusion to vital organs.
C) Incorrect. Warm, flushed skin may be present in the initial stages of hypovolemia, but it is not necessarily an early sign of compensatory response.
D) Incorrect. Decreased urine output is a later sign of hypovolemia when the body's compensatory mechanisms are no longer effective in maintaining blood flow to the kidneys.
Correct Answer is D
Explanation
A) Incorrect. Hemoglobin levels may initially be normal or slightly decreased, but they would decrease later due to the body's compensatory response to dilute the remaining blood.
B) Incorrect. Platelet count may not be significantly affected in the early stages of hemorrhage. It is mainly responsible for clot formation, which becomes more relevant in the later stages.
C) Incorrect. In the early stages of hemorrhage, the white blood cell count is not significantly affected. It plays a role in fighting infection and inflammation.
D) Correct. Hematocrit levels represent the proportion of red blood cells in the blood. During early stages of hemorrhage, there is a loss of red blood cells, leading to decreased hematocrit levels.
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