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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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is choice A. Auscultate the client's abdomen for bowel sounds. This is the first action the nurse should take because it provides information about the client's bowel motility and function. Opioid medications can decrease bowel motility and cause constipation. The nurse should assess the client's abdomen before implementing any interventions.

Choice B is not correct because providing privacy and a set time to defecate is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take.
Choice C is not correct because administering a fiber-based laxative is a pharmacological intervention that can help treat constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid intake and preference before giving a laxative.
Choice D is not correct because encouraging the client to increase oral intake of fluids is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid balance and medical condition before giving fluids.

A. Obtain blood pressure readings using the client's right arm. B. Limit range-of-motion exercises with the affected arm. C. Keep both arms below the level of the client's heart. D. Use the client's left arm to obtain blood samples.

Correct Answer is D

Explanation

The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.

A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.

B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.

C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?

Correct Answer is A

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A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

Correct Answer is D

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