The Nurse Is Assisting a Client to Ambulate Several Hours

question 23

Multiple Choice

The nurse is assisting a client to ambulate several hours after his surgery.The client coughs and says to the nurse,"I feel like something ripped in my incision." A large amount of blood is suddenly apparent on the client's gown near the incision.What action does the nurse take first?

• A) Ease the client to the floor and call for assistance.
• B) Put immediate pressure over the incision with the hands.
• C) Call the Rapid Response Team to assess the client.
• D) Lift up the gown and take off the dressing.

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