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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 A

Explanation

Fluid overload is a potential complication of blood transfusion, and dyspnea is one of the hallmarks of fluid overload. Other signs and symptoms of fluid overload include a headache, hypertension, jugular vein distention, rapid breathing, and tachycardia.

An explanation for incorrect choices:

B. Fever is generally not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a febrile non-hemolytic transfusion reaction.

C. Pruritus is typically not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as an allergic reaction.

D. Bradycardia is not typically associatedwith fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a hemolytic transfusion reaction.

A. "I should consume fish once per week." B. "With a BMI of 30, I should focus on maintaining my current weight." C. "I should consume no more than 2,000 milligrams of sodium per day." D. "I should exercise for 30 minutes three times per week."

Correct Answer is C

Explanation

"I should consume no more than 2,000 milligrams of sodium per day." This is an appropriate statement because consuming too much sodium is associated with an increased risk for hypertension.

Choice A is not correct because there is not enough evidence to support the idea that consuming fish once per week can prevent hypertension.

Choice B is not correct because maintaining a healthy weight is important, but is not as directly related to preventing hypertension as reducing sodium intake.

Choice D is not correct because exercising 30 minutes three times per week is not enough to prevent hypertension.

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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 monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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