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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice a) is incorrect because elevating the client’s feet is not the priority action for a hypotensive client. Elevating the client’s feet may help increase the venous return to the heart, but it may also compromise the respiratory status of a client who has esophageal varices and is at risk of aspiration.

Choice b) is incorrect because administering a unit of packed RBCs is not the priority action for a hypotensive client. Administering a unit of packed RBCs may help increase the oxygen-carrying capacity of the blood, but it may also increase the blood viscosity and pressure, which can worsen the bleeding from the esophageal varices.

Choice c) is incorrect because initiating a dopamine IV infusion for the client is not the priority action for a hypotensive client. Initiating a dopamine IV infusion may help increase the blood pressure and cardiac output, but it may also cause vasoconstriction and tachycardia, which can increase the risk of hemorrhage and arrhythmias.

Choice d) is correct because increasing the client’s IV ﬂuid rate is the priority action for a hypotensive client. Increasing the client’s IV ﬂuid rate may help restore the intravascular volume and perfusion, which can prevent shock and organ damage. Increasing the client’s IV ﬂuid rate may also dilute the blood and reduce its viscosity and pressure, which can decrease the bleeding from the esophageal varices.

A. Place ice to the bridge of the client’s nose. B. Tilt the client's head backward C. Move the client into high-Fowler’s position. D. Instruct the client to blow his nose. E. Apply pressure to the nares.

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

Explanation

Choice A Reason: This is correct because placing ice to the bridge of the client’s nose can cause vasoconstriction and reduce blood ﬂow to the nasal mucosa.

Choice B Reason: This is incorrect because tilting the client's head backward can cause blood to drain into the throat and increase the risk of aspiration, nausea, and vomiting.

Choice C Reason: This is correct because moving the client into high-Fowler position can lower the blood pressure in the head and neck and decrease bleeding.

Choice D reason Reason This is incorrect because instructing the client to blow his nose can dislodge any clots that have formed and worsen bleeding.

Choice E Reason: This is correct because applying pressure to the nares can compress the bleeding site and promote clotting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse’s priority?

Correct Answer is D

Explanation

A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

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