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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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Correct Answer is C

Explanation

The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.

Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.

Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.

Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.

A. Temperature 37.3° C (99.1° F) B. WBC Count 9,000/mm3 C. Changed mental status D. Diminished reflexes

Correct Answer is C

Explanation

A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.

A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.

B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.

D: Diminished reflexes are not typically associated with a bladder infection.

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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

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