After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?
A. Call for help.
B. Obtain vital signs.
C. Ask the client to “lift up”.
D. Apply gloves and assess the groin site.
Correct Answer: D. Apply gloves and assess the groin site.
Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determines how much blood has been lost. The goal in this situation is to stop the bleeding.
Option A: The nurse would call for help if it were warranted after the assessment of the situation.
Option B: After determining the extent of the bleeding, vital signs assessment is important.
Option C: The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.