A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the client's nose and around the intravenous catheter. What action by the nurse is the priority?
a. Hold pressure over the client's nose for 10 minutes.
b. Take the client's pulse, blood pressure, and temperature.
c. Assess for a bruit or thrill over the arteriovenous fistula. d.
Prepare protamine sulfate for administration.
ANS: D
Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the client's system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.
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