A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Place the client in a modified Trendelenburg position.

Apply a tourniquet just above the wound.

Start two large-bore IV catheters.

Apply pressure directly to the wound.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Placing the client in a modified Trendelenburg position is not the first intervention for a client with a deep laceration and heavy bleeding. This position involves tilting the patient with the head lower than the feet and is typically used to improve venous return in certain situations, such as hypovolemic shock. However, for a bleeding wound, the priority is to control the bleeding itself.

Choice B rationale:

Applying a tourniquet just above the wound is a drastic measure and is generally not the first intervention for controlling bleeding. Tourniquets are used when direct pressure and other methods are unsuccessful, as they can lead to complications such as tissue damage and ischemia if not used correctly.

Choice C rationale:

Starting two large-bore IV catheters is important for fluid resuscitation in cases of significant bleeding. However, it is not the first intervention. Directly controlling the bleeding takes precedence to prevent further blood loss.

Choice D rationale:

Applying pressure directly to the wound is the correct answer. This is the initial and immediate action to take when dealing with a heavily bleeding wound. Applying pressure helps to stem the bleeding by promoting clot formation and reducing blood loss. It is a vital step in managing the client's condition and preventing further deterioration.

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Correct Answer is C

Explanation

Choice A rationale:

Decreased tactile fremitus refers to a decreased vibration felt upon palpation of the chest, which might be indicative of conditions such as pleural effusion or pneumothorax. It is not directly associated with a crackling sensation.

Choice B rationale:

Pleural friction fremitus occurs when inflamed pleural surfaces rub against each other during breathing. It typically results in a grating sensation rather than a crackling sensation. It is associated with conditions like pleuritis.

Choice C rationale:

(Correct Choice) Crepitus refers to a crackling or grating sound/sensation that occurs when gas or air accumulates in the subcutaneous tissue. It can indicate a serious condition, such as subcutaneous emphysema, which might result from lung or chest wall injury, infections, or surgery.

Choice D rationale:

Rhonchal fremitus is associated with coarse breath sounds caused by thick secretions in the larger airways. It is felt as vibration during palpation and is not related to crackling sensations.

A. Rectus Femoris. B. Vastus Lateralis. C. Dorsogluteal. D. Lower abdomen. E. Deltoid.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

The choice "Rectus Femoris" is not the correct answer. The rectus femoris is a muscle located in the thigh and is not a common site for intramuscular injections due to its location and proximity to important structures.

Choice B rationale:

The correct answer is "Vastus Lateralis." Choice B is the correct answer. The vastus lateralis muscle is located on the lateral aspect of the thigh and is a suitable site for intramuscular injections. It is often used in infants and young children or in adults who have limited deltoid muscle mass.

Choice C rationale:

The correct answer is "Dorsogluteal." Choice C is the correct answer. The dorsogluteal muscle, located in the buttocks, has historically been used for intramuscular injections. However, it's important to note that due to the proximity of the sciatic nerve and the potential for incorrect injection technique, this site is used less frequently now.

Choice D rationale:

The choice "Lower abdomen" is not the correct answer. The lower abdomen is not a recommended site for intramuscular injections due to the risk of injuring underlying structures and the potential for subcutaneous injection instead of intramuscular.

Choice E rationale:

The correct answer is "Deltoid." Choice E is the correct answer. The deltoid muscle, located in the upper arm, is commonly used for intramuscular injections, especially for vaccines and smaller medication volumes. However, it has a limited muscle mass and may not be suitable for larger injection volumes.

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A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is examining the chest of a post-operative client. Upon palpation, the nurse notes a crackling sensation. Which of the following conditions would the nurse report to the provider?

Correct Answer is C

Explanation

A nurse on a Medical-Surgical unit is preparing to administer an intramuscular injection to a client. Which of the following sites can the nurse use? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

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