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 D

Explanation

Choice A reason: Humidifying the client's room can help maintain mucous membrane integrity and prevent respiratory infections, which is crucial for a client with a low WBC count.

Choice B reason: Replacing the water in flower vases daily can prevent the growth of bacteria, reducing the risk of infection for an immunocompromised client.

Choice C reason: Cleaning dentures in a denture cup is a standard infection control practice that helps maintain oral hygiene and prevent infections.

Choice D reason: Serving cooked fruit with meals reduces the risk of transmitting infections that can be associated with raw fruits, which is important for a client with neutropenia.

A. Prone B. Lateral C. Supine D. Upright

Correct Answer is D

Explanation

Choice A reason: The prone position is not suitable for abdominal paracentesis as it does not allow access to the abdominal cavity.

Choice B reason: The lateral position is also not suitable as it can cause the fluid to shift, making it difficult to remove.

Choice C reason: While the supine position is commonly used for many medical procedures, it is not the best choice for abdominal paracentesis due to the distribution of fluid.

Choice D reason: The upright position is preferred because it allows the fluid to pool at the lowest point of the abdominal cavity, facilitating its removal.

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