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A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next?

Maintain direct pressure over the site.

Check whether the bleeding has stopped.

Obtain a radial pulse.

Reinforce the dressing over the site.

Answer and Explanation

The Correct Answer is A

The correct answer is: Choice A: Maintain direct pressure over the site.

Here's the rationale for each choice:

Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Apply foam handles to the client's eating utensils. This intervention can help the client grip the utensils better and improve their ability to eat.

Reasons why the other options are not answers:

Option A: Having an assistive personnel feed the client may decrease the client's autonomy.

Option C: Obtaining a referral for physical therapy may be helpful but does not address the immediate issue of difficulty with eating.

Option D: Asking the provider for a prescription for a pureed diet may not be necessary or desirable at this time.

A. Recent exposure to tuberculosis B. History of generalized anxiety disorder C. Reports periodic migraine headaches D. Experiences nocturia E. Experiences nocturia

Correct Answer is A

Explanation

Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis. Options B, C, and D are not urgent and can be addressed after addressing option A.

Reasons why the other options are not answers:

Option B: A history of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention.

Option C: Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.

Option D: Experiencing nocturia is not an urgent issue that requires the nurse's immediate attention.

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A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next?

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