A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh.
Which of the following actions should the nurse take?
Tie a tourniquet around the leg distal to the wound.
Irrigate the wound with sterile water.
Apply direct pressure to the wound with thick dressing material.
Apply a transparent dressing to the wound.
The Correct Answer is C
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Applying skin sealant on damp skin is not a correct technique when changing an ostomy appliance. Skin should be clean and thoroughly dry before applying any ostomy products. Moisture on the skin can interfere with the adhesion of the pouching system, leading to skin irritation and leakage.
Choice B rationale:
Removing the appliance before emptying the pouch is not the correct technique. Ostomy pouches are designed to be emptied without removing the entire appliance. Removing the pouch unnecessarily can cause discomfort to the client and may damage the surrounding skin. Regular emptying of the pouch while leaving the appliance in place is the appropriate practice.
Choice C rationale:
Ensuring that the skin is slightly damp for better adhesion of the pouch is not accurate. Ostomy pouches adhere best to clean, dry skin. Moisture on the skin can compromise the adhesive seal and lead to skin irritation. Therefore, the skin should be thoroughly dried before applying the ostomy pouching system.
Choice D rationale:
Tracing the size of the stoma onto the skin barrier is the correct technique when changing an ostomy appliance. The opening of the skin barrier (wafer) should match the size and shape of the stoma to ensure a proper fit. Tracing the stoma's size onto the barrier helps in cutting the opening to the appropriate size, preventing leakage and ensuring a secure fit around the stoma.
Correct Answer is C
Explanation
The correct answer is Choice C, the system is working properly.
Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained
Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops
Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped
Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.