Following a mitral valve replacement, the client suddenly begins to show a large amount of blood on the surgical dressing while in the postanesthesia care unit (PACU). Which intervention should the nurse implement first?
Apply topical fibrin directly to the incision.
Reinforce the incisional dressing.
Increase the intravenous fluid rate.
Obtain samples for coagulation studies.
The Correct Answer is B
A. Apply topical fibrin directly to the incision: Topical fibrin application is a provider-initiated intervention. It is not within the nurse’s scope to apply this independently in the PACU setting and should not delay immediate nursing actions to control visible bleeding.
B. Reinforce the incisional dressing: A sudden large amount of blood on the surgical dressing indicates potential hemorrhage. Reinforcing the dressing is the first nursing action to help control bleeding, prevent further blood loss, and allow assessment of bleeding progression while the provider is being notified.
C. Increase the intravenous fluid rate: Increasing IV fluids may help manage hypotension related to blood loss but administering fluids without first attempting to control or quantify bleeding may worsen outcomes if bleeding is uncontrolled.
D. Obtain samples for coagulation studies: Laboratory evaluation is necessary to assess for coagulopathy but is not the immediate priority. Stabilizing the client by addressing active bleeding takes precedence, after which labs can guide further treatment decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply topical fibrin directly to the incision: Topical fibrin application is a provider-initiated intervention. It is not within the nurse’s scope to apply this independently in the PACU setting and should not delay immediate nursing actions to control visible bleeding.
B. Reinforce the incisional dressing: A sudden large amount of blood on the surgical dressing indicates potential hemorrhage. Reinforcing the dressing is the first nursing action to help control bleeding, prevent further blood loss, and allow assessment of bleeding progression while the provider is being notified.
C. Increase the intravenous fluid rate: Increasing IV fluids may help manage hypotension related to blood loss but administering fluids without first attempting to control or quantify bleeding may worsen outcomes if bleeding is uncontrolled.
D. Obtain samples for coagulation studies: Laboratory evaluation is necessary to assess for coagulopathy but is not the immediate priority. Stabilizing the client by addressing active bleeding takes precedence, after which labs can guide further treatment decisions.
Correct Answer is D
Explanation
A. Accelerated junctional rhythm: An accelerated junctional rhythm originates in the AV junction (40-100 bpm), typically has absent, inverted, or hidden P waves (before, during, or after QRS), and a regular rhythm. This strip has clear, upright P waves, an irregular rhythm, and a lengthening PR interval.
B. Premature atrial contractions (PAC): PACs are single ectopic beats that occur earlier than expected, originating in the atria. While they involve P waves, they don't show a pattern of progressively lengthening PR intervals or dropped beats in the characteristic Wenckebach pattern.
C. Atrial fibrillation (A-fib): Atrial fibrillation is characterized by irregularly irregular R-R intervals, chaotic atrial activity with no discernible P waves, and a variable ventricular rate. This strip clearly shows discernible P waves.
D. Wenckebach, Mobitz Type I atrioventricular (AV) block: This rhythm is defined by a progressive lengthening of the PR interval until a QRS complex is dropped. The cycle then repeats. This is what is observed in the ECG strip.
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