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.
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Related Questions
Correct Answer is B
Explanation
A) Incorrect. While resuming normal activities is important, the client should also be cautious and monitor for any complications after a blood transfusion.
B) Correct. Monitoring for signs of infection at the transfusion site is crucial to identify any potential complications such as infection or infiltration.
C) Incorrect. Consuming citrus fruits and juices is not contraindicated after a blood transfusion and does not directly impact post-transfusion care.
D) Incorrect. Dark-colored stools are not an expected outcome after a blood transfusion. It is important for the client to be aware of any unusual changes in stool color or other potential side effects.
Correct Answer is C
Explanation
A) Incorrect. Aspirin is an antiplatelet medication and can increase the risk of bleeding, so it should be avoided in clients at risk of hemorrhage.
B) Incorrect. Encouraging the client to participate in contact sports can increase the risk of trauma and bleeding, and it is not a preventive action.
C) Correct. Using a soft-bristled toothbrush for oral care can prevent gum and oral tissue injury, reducing the risk of bleeding in vulnerable clients.
D) Incorrect. Monitoring platelet levels daily is not a preventive action but a method of assessing the client's clotting status.
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