The nurse inspects the client's surgical incision in the postanesthesia care unit and notes severe hemorrhaging. Which is the most important intervention for the nurse to implement?
1. Call for assistance.
2. Take blood pressure.
3. Apply direct pressure.
4. Apply a pressure dressing.
3
3. The most important intervention for the nurse is to apply direct pressure to the in-cision to stop blood loss because, if it continues, severe client blood loss poses life-threatening and organ-damaging consequences for the client.
1. The nurse calls for help after directly addressing the bleeding because the client needs additional assessments, fluid resuscitation with crystalloids and colloids, sur-gical attention, and, potentially, cardiopulmonary support.
2. The nurse directs colleagues responding to the call for help to assess the vital signs to help complete the client assessment. The client is probably hypotensive, tachycar-dic, and, hypoxic. Saving vital organs is critical for a positive client outcome and re-quires a minimum blood pressure of 80 mm Hg to prevent tissue hypoxia, especially in the kidneys and brain.
4. Depending on the severity of the hemorrhage, the nurse potentially maintains direct pressure to the surgical site until the surgical team can address the problem. Once the bleeding is under control, the nurse applies a pressure dressing to provide continuing support over the incision and facilitate hemostasis.
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A woman has just experienced a spontaneous abortion. Which information would the nurse analyze before counseling the client?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. What was the fetal gestational age? 2. Are malformations present? 3. What is the father's ethnicity? 4. What is the mother's age? 5. Is the fetus small for gestational age?
The nurse is counseling a family with a 10-year-old child after the death of a favorite uncle. The nurse provides guidance to the parents, informing them that the child may exhibit which of the following as a response?
A) "Talk about scary, morbid novels all the time." B) "Complain of aches and pains, stomachaches, that sort of thing." C) "Suddenly become afraid of leaving home to go to school." D) "Become obsessed with religious rituals, Bible verses, and prayer."
The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This is an example of what learning theory?
A) Adaptive learning theory B) Behavioral learning theory C) Cognitive learning theory D) Developmental learning theory
Infection can be transmitted by
A) touching sterile items. B) disinfecting equipment. C) blood and body fluids. D) wearing gloves.