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 B
Explanation
The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.
Option A is incorrect because breast cancer is not associated with false-positive fecal occult blood results.
Option C is incorrect because citrus juice does not affect the fecal occult blood test.
Option D is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.
Reasons why the other options are not answered:
Option A: Breast cancer is not associated with false-positive fecal occult blood results.
Option C: Citrus juice does not affect the fecal occult blood test.
Option D: A hemorrhoidectomy is not associated with false-positive fecal occult blood results.
Correct Answer is A
Explanation
Epoetin alfa is a medication used to stimulate erythropoiesis, the production of red blood cells. An increase in the client's hemoglobin level indicates that the medication has been effective. The normal range of hemoglobin for adult females is 12-16 g/dL and for adult males is 13.5-17.5 g/dL. A hemoglobin level of 11 g/dL is slightly below the normal range, but it is an improvement from a lower level. Choice B, WBC count 9,000/mm3 is unrelated to the medication and is within the normal range. Choice
C, total calcium 10 mg/dL, and choice D, PT 12 seconds, are also unrelated to the medication and are within the normal range.
Choice B (WBC count 9,000/mm3) is not an answer because it is unrelated to the medication and is within the normal range.
Choice C (total calcium 10 mg/dL) is not an answer because it is unrelated to the medication and is within the normal range.
Choice D (PT 12 seconds) is not an answer because it is unrelated to the medication and is within the normal range.
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