The nurse is caring for a patient with pernicious anemia immediately following a bone marrow biopsy of the left posterior iliac crest. Which action should the nurse perform first?
a. Inform the patient that he may feel pres-sure and sharp, brief pain.
b. Check the pulses in the leg and foot distal to the puncture.
c. Administer an ordered analgesic.
d. Apply pressure to the site for 5 minutes with an ice pack.
D
The most immediate priority concern for this patient is bleeding. The nurse should apply pressure to the site to prevent a hematoma. The patient would feel pressure and sharp brief pain during the aspiration, not afterward. The nurse can assess pulses in the leg and foot, although this assessment would be most appropriate if the procedure involved an arterial stick. The nurse should administer the ordered analgesic after hemostasis is obtained.
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