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. Acute blood loss does not typically lead to a decreased platelet count. Platelet levels may remain within the normal range or slightly decrease due to hemodilution.
B) Correct. In acute blood loss, the concentration of red blood cells decreases, leading to hemoconcentration and elevated hemoglobin levels. This is the body's initial response to conserve oxygen-carrying capacity.
C) Incorrect. An increased white blood cell count is not a direct result of acute blood loss and may indicate other inflammatory or infectious processes.
D) Incorrect. Elevated liver enzymes are not a typical finding in acute blood loss. They are more indicative of liver injury or dysfunction.
Correct Answer is B
Explanation
A) Incorrect. Topical antiseptics, such as hydrogen peroxide or alcohol, can help prevent infection but are safe to use on minor cuts when applied correctly.
B) Correct. Applying direct pressure to the bleeding site for at least 10 minutes helps control minor bleeding and allows the blood to clot, reducing the risk of excessive bleeding.
C) Incorrect. Aspirin is an antiplatelet medication and can increase the risk of bleeding. It should not be used to stop bleeding quickly without medical guidance.
D) Incorrect. Elevating the affected limb above the heart level is not typically necessary for minor bleeding episodes and may not be practical for all bleeding sites.
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