A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?
Clean the wound.
Apply a tourniquet just below the elbow.
Apply direct pressure over the wound.
Elevate the limb and apply ice.
The Correct Answer is C
Choice A Reason: This is incorrect because cleaning the wound is not a priority when the client is bleeding profusely. Cleaning the wound can also dislodge any clots that have formed and increase bleeding.
Choice B Reason: This is incorrect because applying a tourniquet is a last resort when direct pressure fails to stop bleeding. A tourniquet can cause tissue damage, nerve injury, and infection if applied incorrectly or for too long.
Choice C Reason: This is correct because applying direct pressure over the wound is the first and most effective action to stop bleeding from a wound. This is the first and most effective action to stop bleeding from a wound. Direct pressure compresses the blood vessels and prevents further blood loss. The nurse should use a clean cloth or dressing to cover the wound and apply firm pressure with both hands.
Choice D Reason: This is incorrect because elevating the limb and applying ice are not effective actions to stop bleeding from a wound. Elevating the limb can reduce blood flow to the injured area, but it does not compress the blood vessels or prevent blood loss. Applying ice can cause vasoconstriction, but it can also damage the skin and tissues if applied for too long.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: A. Elective cardioversion
Choice A reason:
Elective cardioversion is a medical procedure that is used to restore a normal heart rhythm in patients experiencing certain types of arrhythmias, including ventricular tachycardia (VT), when they are stable. It involves the delivery of a controlled electric shock to the heart, which is synchronized with the heart's electrical activity to convert the abnormal rhythm back to a normal sinus rhythm. This procedure is typically performed when VT is not causing hemodynamic instability and the patient is not in immediate danger.
Choice B reason:
Defibrillation is an emergency treatment for life-threatening cardiac arrhythmias, particularly ventricular fibrillation (VF) or pulseless ventricular tachycardia. It involves delivering a high-energy electric shock to the heart unsynchronized to the heart's electrical cycle, aiming to reset the heart's electrical state and allow it to reestablish an effective rhythm. In the scenario provided, where the patient is experiencing VT but not VF, defibrillation would not be the first line of action unless the VT deteriorates into VF or the patient becomes pulseless.
Choice C reason:
CPR, or cardiopulmonary resuscitation, is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. In the case of VT, if the patient is conscious and has a pulse, CPR is not indicated. CPR would only be necessary if the patient's heart stops beating (cardiac arrest) as a result of the VT.
Choice D reason:
Radiofrequency catheter ablation is a procedure used to treat some types of arrhythmias, including VT, by destroying the area of heart tissue that is causing the abnormal heart rhythm. This treatment is generally considered when medication is ineffective or not tolerated, or in recurrent VT. It is not typically the first line of treatment in an acute setting where the patient is stable and experiencing VT.
Correct Answer is A
Explanation
Choice A: Provide frequent oral and nares care is the correct action for the nurse to take. Oral and nares care can help prevent infection, dryness, and irritation of the mucous membranes, which can be damaged by the pressure and friction of the tube. The nurse should also monitor the tube position, secure it with tape, and keep scissors at the bedside in case of emergency deflation.
Choice B: Keep the client in a supine position is not the correct action for the nurse to take. The supine position can increase the risk of aspiration, regurgitation, and gastric distension, which can worsen the bleeding and compromise the airway. The nurse should elevate the head of the bed to at least 30 degrees and use a semi-Fowler's or high-Fowler's position.
Choice C: Ambulating the client four times per day is not the correct action for the nurse to take. Ambulation can increase abdominal pressure and dislodge the tube, which can cause bleeding and perforation. The nurse should keep the client on bed rest and use passive range-of-motion exercises to prevent complications such as thromboembolism and muscle atrophy.
Choice D: Encouraging the client to consume clear liquids is not the correct action for the nurse to take. Clear liquids can increase gastric volume and acidity, which can aggravate the bleeding and interfere with hemostasis. The nurse should maintain a nothing-by-mouth status and provide intravenous fluids and nutrition as prescribed.
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