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 A

Explanation

Choice A: Troponin I is a laboratory test that the nurse should anticipate the provider to prescribe. Troponin I is a protein that is released into the blood when the heart muscle is damaged. Troponin I levels are elevated in clients who have acute myocardial infarction (AMI), which is a heart atack caused by a blockage of blood ﬂow to the heart. Chest pressure and shortness of breath are common signs and symptoms of AMI. Troponin I is a specific and sensitive marker of cardiac injury and can help diagnose AMI and guide treatment.

Choice B: Aspartate aminotransferase (AST) is not a laboratory test that the nurse should anticipate the provider to prescribe. AST is an enzyme that is found in various tissues, such as the liver, heart, skeletal muscle, and kidneys. AST levels are elevated in clients who have liver damage, hepatitis, cirrhosis, or alcohol abuse. AST levels can also be elevated in clients who have AMI, but they are not as specific or sensitive as troponin I. AST is not a reliable indicator of cardiac injury and can be inﬂuenced by other factors.

Choice C: B-type natriuretic peptide (BNP) is not a laboratory test that the nurse should anticipate the provider to prescribe. BNP is a hormone that is secreted by the heart when it is stretched or overloaded. BNP levels are elevated in clients who have heart failure, which is a condition in which the heart cannot pump enough blood to meet the

body's needs. Shortness of breath can be a sign of heart failure, but chest pressure is not. BNP is not a specific or sensitive marker of cardiac injury and can be inﬂuenced by other factors.

Choice D: Lipase is not a laboratory test that the nurse should anticipate the provider to prescribe. Lipase is an enzyme that is produced by the pancreas and helps digest fats. Lipase levels are elevated in clients who have pancreatitis, which is an inﬂammation of the pancreas. Pancreatitis can cause abdominal pain, nausea, vomiting, and fever. Chest pressure and shortness of breath are not signs of pancreatitis. Lipase is not a specific or sensitive marker of cardiac injury and has no relation to AMI.

A. Nausea B. Severe dyspnea C. Headache D. Decreased level of consciousness E. Hypotension

Correct Answer is ["B","C","D","E"]

Explanation

Choice a) is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of discomfort in the stomach that may or may not lead to vomiting. Nausea can be caused by many other conditions, such as gastroenteritis, motion sickness, or pregnancy.

Choice b) is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective feeling of difficulty or discomfort in breathing. Severe dyspnea indicates that the client is not getting enough oxygen and may have low blood oxygen levels (hypoxemia) or high carbon dioxide levels (hypercapnia).

Choice c) is correct because headache is a common manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can be caused by high carbon dioxide levels (hypercapnia), which can affect the blood vessels and nerves in the brain.

Choice d) is correct because a decreased level of consciousness is a common manifestation of ARF. Level of consciousness is a measure of how alert and oriented a person is. A decreased level of consciousness can be caused by low blood oxygen levels (hypoxemia), high carbon dioxide levels (hypercapnia), or acid-base imbalance, which can aﬀect brain function and mental status.

Choice e) is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal. Hypotension can be caused by low blood oxygen levels (hypoxemia), which can impair heart function and reduce cardiac output.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Correct Answer is A

Explanation

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Correct Answer is ["B","C","D","E"]

Explanation

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