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 C
Explanation
Choice A reason: Weighing the client daily is important for monitoring fluid balance but is not the most immediate action to prevent an Addisonian crisis.
Choice B reason: Restricting fluid intake is not appropriate for a client at risk for Addisonian crisis, as they may require increased fluids to prevent dehydration.
Choice C reason: This is the correct action. Clients with Addison's disease require corticosteroids to replace the hormones that their adrenal glands are not producing.
Choice D reason: Providing a low carbohydrate diet is not relevant to the prevention of an Addisonian crisis.
Correct Answer is B
Explanation
Choice A reason: This choice is incorrect. Metabolic alkalosis would be indicated by an elevated pH and HCO3, but the PaCO2 would typically be higher due to compensatory hypoventilation.
Choice B reason: This is the correct choice. The elevated pH and low PaCO2 indicate respiratory alkalosis, likely due to hyperventilation. The normal HCO3 suggests that there has been no renal compensation, hence 'uncompensated'.
Choice C reason: This choice is incorrect because, for metabolic alkalosis to be uncompensated, the PaCO2 would typically be normal or high, not low.
Choice D reason: This choice is incorrect. Respiratory acidosis would be indicated by a low pH and high PaCO2, which is not the case here.
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