A client was just admitted to the emergency department for new-onset confusion. As the nurse starts the IV line, the client says he just finished a hemodialysis session. The IV site is bleeding briskly. What action by the nurse takes priority?
a. Assess for a bruit and thrill over the vas-cular access site.
b. Draw blood for coagulation studies and white blood cell count.
c. Prepare to administer protamine sulfate.
d. Hold constant firm pressure with a gauze pad for 5 minutes.
C
To prevent blood clots from forming within the dialyzer or blood tubing, anticoagulation is needed during hemodialysis treatment. The drug used is heparin, which makes the client at risk for hemorrhage for the next 4 to 6 hours. Protamine sulfate is the antidote to heparin, and the nurse should prepare to administer it. Pressure may help, and someone else can apply it while the nurse is getting the medication. Laboratory studies are not needed because the client is at known risk for bleeding from heparin. Assessing the vascular access device does nothing to help the situation.
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