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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice D rationale:

This statement by an assistive personnel (AP) indicates a need for further teaching. Hand hygiene is crucial to prevent the transmission of microorganisms, and it involves both handwashing and the appropriate use of gloves. Changing gloves between clients is important to prevent cross-contamination, but it doesn't replace the need for handwashing. Hands can become contaminated even with the use of gloves, and proper hand hygiene should be practiced before and after glove use.

Choice A rationale:

The statement about using alcohol-based hand products after most client contact is accurate. Alcohol-based hand sanitizers are effective in reducing the number of microorganisms on the hands when soap and water are not readily available. They are especially useful in healthcare settings.

Choice B rationale:

Washing hands before providing client care is a fundamental principle of infection control. It helps remove dirt, debris, and transient microorganisms from the hands, reducing the risk of infection transmission.

Choice C rationale:

The statement about not wearing artificial nails when providing client care is correct. Artificial nails can harbor microorganisms and are challenging to clean thoroughly. They pose an infection risk and are generally not recommended for healthcare workers who provide direct patient care.

A. The left fifth intercostal space at the midclavicular line. B. The left fifth intercostal space. C. The left second intercostal space. D. The right second intercostal space.

Correct Answer is C

Explanation

A. The left fifth intercostal space at the midclavicular line is the location for palpating the apical pulse, not the pulmonic area. This area is used to assess the heart's apex, particularly for detecting the point of maximal impulse (PMI).

B. The left fifth intercostal space is also associated with the apical pulse, but it lacks the specificity of the midclavicular line, making it less precise for identifying the pulmonic area.

C. The left second intercostal space is the correct location for palpating the pulmonic area. This area is where the pulmonic valve is best auscultated and palpated, allowing for the detection of any abnormal pulsations or sounds related to the pulmonary artery.

D. The right second intercostal space is the location for palpating the aortic area, not the pulmonic area. This site is used to assess the aortic valve and any related abnormalities.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

Correct Answer is D

Explanation

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

Correct Answer is C

Explanation

A nurse on the Medical-Surgical unit is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.).

A nurse is assessing a client in a Community Clinic. In accordance with Maslow's Hierarchy of needs, which of the following needs will the client seek to meet first?

A nurse is assessing a patient who has chronic bronchitis. The nurse should expect the patient's chest to be which of the following shapes?

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?