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 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. Apply petroleum jelly to the nares as needed to soothe mucous membranes. B. Remove the nasal cannula while the client eats. C. Attach a humidifier bottle to the base of the flow meter. D. Secure the oxygen tubing to the bed sheet near the client's head.

Correct Answer is D

Explanation

Choice A rationale:

Applying petroleum jelly to the nares is not necessary in this situation. Oxygen therapy through a nasal cannula aims to deliver oxygen to the client's respiratory system. Applying petroleum jelly might interfere with the oxygen delivery and is not a standard practice.

Choice B rationale:

Removing the nasal cannula while the client eats reduces the oxygen supply during a time when the body's oxygen demand might increase due to the digestive process. It's important to maintain consistent oxygen therapy, even during meals.

Choice C rationale:

Attaching a humidifier bottle to the base of the flow meter is not necessary for oxygen therapy at 5 L/min via nasal cannula. Humidification is usually needed at higher oxygen flow rates to prevent drying of the mucous membranes.

Choice D rationale:

Securing the oxygen tubing to the bed sheet near the client's head is the correct action. This ensures that the tubing is not pulled or tugged during movement, maintaining a steady flow of oxygen. Placing it near the client's head prevents kinking or tangling of the tubing and allows the client to move without disrupting the therapy.

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 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 is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse on a Medical-Surgical unit is performing an assessment on a client who has COPD with emphysema. The client reports that he has a frequent wet cough and is occasionally short-of-breath. The nurse should anticipate which of the following assessment findings for this client?

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

While preparing to administer the patient's scheduled medications, the nurse does not understand why the client will be receiving one of the prescribed drugs. What action should the nurse take?

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

A nurse is interviewing a female client who is Hispanic. The client's husband answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take?

A Medical-Surgical nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?

A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?