The nurse admits a client who has fallen from a ladder to the Emergency Department with a deep wound on the leg. There is a blood-saturated pressure dressing on the wound
The nurse assesses the client and finds a heart rate of 128, respirations of 30, and blood pressure of 92/50. The priority action by the nurse at this time is which of the following? 1. Notify the physician immediately.
2. Reinforce the pressure dressing and elevate the extremity.
3. Remove the pressure dressing, assess the wound, and apply a new dressing.
4. Start an IV line for the administration of fluids.
2
Rationale: The client is in shock from blood loss, as indicated by vital signs. The priority action is to prevent further loss of blood by reinforcing the current pressure dressing. Removing the old dressing will result in increased blood loss. While the nurse might need to call the physician, the dressing should be reinforced first in order to prevent further blood loss before the physician arrives. An IV line requires an order, and cannot be placed independently by the nurse.
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