A client who is receiving a heparin infusion calls the nurse to report sudden bleeding from the nose and mouth. Which action is most important for the nurse to implement?

Rationale: A. Apply pressure and ice to the nasal bridge.: Applying direct pressure and a cold compress helps constrict blood vessels and reduce bleeding quickly, making this the immediate priority before further interventions can be initiated. B. Encourage the client to remain sitting upright.: Sitting upright may reduce venous pressure and slow bleeding, but it does not directly control the hemorrhage. It is supportive but not the most immediate intervention. C. Flush the IV site with normal saline to maintain patency.: Maintaining IV patency is not the priority when the client is experiencing active bleeding. The focus should be on controlling hemorrhage first. D. Give a PRN dose of protamine sulfate subcutaneous.: Protamine sulfate is the antidote for heparin, but it is administered IV, not subcutaneously. It also requires a provider’s order and is not the nurse’s first immediate action.