A patient returns from a procedure and suddenly becomes restless, with cool skin and a rapid weak pulse. The dressing is soaked with fresh blood. What should the nurse do first?
Correct answer: A. Apply firm pressure to the bleeding site
- A. Apply firm pressure to the bleeding site
- B. Remove the dressing to inspect the wound fully
- C. Offer prescribed analgesia before taking action
- D. Place the patient in a standing position
Explanation
Fresh heavy bleeding with signs of poor perfusion requires immediate control of external haemorrhage. The nurse applies firm pressure over the dressing, calls for urgent assistance, and assesses circulation and responsiveness. Removing the dressing may disrupt clot formation and worsen blood loss.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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