The client is receiving heparin by continuous intravenous infusion. While getting out of bed, the client lacerates her arm on the bed rail. The laceration begins to bleed profusely. What is the first action of the nurse?
a. Call the health care provider.
b. Prepare an incident report.
c. Apply pressure to the site.
d. Check the results of the client's last APTT (activated partial thromboplastin time).
ANS: C
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A Incorrect: Although important, this can be delegated to an unlicensed staff.
B Incorrect: This is completed after the client's condition has been stabilized.
C Correct: This is the nurse's first action as basic application of first aid.
D Incorrect: Although important, this is not the first nursing action.
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