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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Keeping the client NPO (nothing by mouth) is not directly related to preventing a thyroid crisis. While it may be necessary in some situations, such as preoperative care, it does not address the hyperthyroid state.

Choice B reason: Observing the client for signs of hypocalcemia is important, especially after thyroid surgery, as hypocalcemia can occur due to accidental removal or damage to the parathyroid glands. However, it is not a preventive measure for a thyroid crisis.

Choice C reason: Providing a quiet, low stimulus environment can help reduce stress and agitation, which are potential triggers for a thyroid crisis. Stress can exacerbate hyperthyroid symptoms and precipitate a crisis.

Choice D reason: Aspirin is contraindicated in clients with hyperthyroidism as it can increase thyroid hormone levels by displacing them from their binding proteins. This can potentially worsen the condition and lead to a crisis.

A. Headache B. Dyspnea C. Red-brown petechiae D. Altered mental status

Correct Answer is B

Explanation

Choice A reason: Headache can be associated with FES; however, it is not typically considered an early sign. It may occur as a part of the broader spectrum of symptoms.

Choice B reason: Dyspnea, or difficulty breathing, is one of the earliest signs of FES. Patients may experience shortness of breath due to fat globules obstructing pulmonary vessels.

Choice C reason: Red-brown petechiae, which are small, pinpoint hemorrhages, can appear on the skin and are a classic sign of FES, often found in the axillary region or on the chest.

Choice D reason: Altered mental status, including confusion and drowsiness, can occur early in FES due to fat emboli traveling to the cerebral circulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a client who is 24 hours postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)?

Correct Answer is B

Explanation

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