A nurse in an emergency department is caring for a patient with a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse take?
Apply a tourniquet just below the elbow.
Elevate the limb and apply ice.
Clean the wound.
Apply pressure above the wound.
The Correct Answer is B
Choice A reason: Applying a tourniquet just below the elbow is not recommended as the first line of action for a deep laceration unless there is life-threatening hemorrhaging that cannot be controlled by direct pressure. Tourniquets are used as a last resort because they can cause tissue damage.
Choice B reason: Elevating the limb and applying ice can help reduce bleeding and swelling. Elevation uses gravity to help reduce blood flow to the injury, and the cold from the ice constricts blood vessels, further helping to control bleeding and reduce swelling.
Choice C reason: Cleaning the wound is important, but it should not be the first action taken. The initial focus should be on stopping the bleeding. Once bleeding is controlled, the wound can be cleaned to prevent infection.
Choice D reason: Applying pressure directly to the wound with a clean cloth or bandage is the first step in controlling bleeding. However, the question specifies applying pressure above the wound, which would not be effective in controlling bleeding from the wound itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This set of values is indicative of metabolic acidosis with respiratory compensation, which is common in chronic kidney disease due to the accumulation of acids in the blood and the lungs' attempt to compensate by retaining CO2.
Choice B reason: This choice suggests respiratory alkalosis, which is less likely in chronic kidney disease unless there is a secondary respiratory condition causing hyperventilation.
Choice C reason: This choice indicates metabolic alkalosis, which is not typical for chronic kidney disease, as the kidneys are unable to excrete acid effectively.
Choice D reason: While this set of values does indicate acidosis, the expected compensatory response in chronic kidney disease would be an elevated PaCO2, not a normal or low value.
Correct Answer is B
Explanation
Choice A reason: Pain is a common postoperative symptom and should be managed appropriately. However, it is not typically considered a priority over other complications that can have more immediate and severe consequences.
Choice B reason: Hemorrhage is a significant risk after TURP and can be life-threatening. It is considered a priority because active bleeding can lead to shock and requires immediate intervention.
Choice C reason: Infection is a potential complication after any surgery, including TURP. While important to monitor for, it is generally not as immediately life-threatening as hemorrhage.
Choice D reason: Urinary retention can occur after TURP, but it is often anticipated and managed with the placement of a urinary catheter. It is a concern but not the highest priority immediately following surgery.
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