A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?
Obtain a complete blood count (CBC)
Start IV fluids
Apply direct pressure
Administer pain medication
The Correct Answer is C
A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.
B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.
C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.
D. Administer pain medication: Pain management is important but not the priority in acute bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Raisins: Dried fruits like raisins are concentrated sources of potassium and should be avoided in CKD.
B. Bananas: Bananas are high in potassium and commonly restricted in CKD to prevent hyperkalemia.
C. Green beans: Green beans are relatively low in potassium and generally safe for a renal diet.
D. Asparagus: Asparagus has moderate potassium levels but can be included in moderation depending on the client's labs.
E. Tomatoes: Tomatoes, especially in processed forms like sauce or juice, are high in potassium.
Correct Answer is D
Explanation
A. Cool and clammy skin:
May indicate shock but is not specific to electrical burns.
B. Purulent drainage from the burn site:
Suggests infection, a later complication rather than immediate concern.
C. Muscle weakness:
Can occur but is less urgent than cardiac effects.
D. Irregular heart rhythm:
Electrical burns can cause internal cardiac damage and arrhythmias-potentially life-threatening.
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