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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Lime ice popsicle.
Choice A rationale:
Orange juice is acidic and can irritate the stomach lining, which is not ideal for someone recovering from gastroenteritis.Acidic foods and drinks can exacerbate symptoms like nausea and stomach pain.
Choice B rationale:
Cream of broccoli soup is not recommended because it is a dairy-based product.Dairy can be difficult to digest and may worsen symptoms like diarrhea and stomach cramps during the recovery phase of gastroenteritis.
Choice C rationale:
Lime ice popsicle is a good choice because it is a clear liquid that can help with hydration and is easy on the stomach.Ice popsicles can also help soothe the throat and provide a small amount of sugar for energy without overwhelming the digestive system.
Choice D rationale:
Vanilla pudding, although soft, contains dairy, which can be hard to digest for someone recovering from gastroenteritis.Dairy products can lead to further gastrointestinal discomfort.
Correct Answer is D
Explanation
Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.
Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.
Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .
Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.
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