A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound.
Which of the following actions should the nurse take first?
Apply a tourniquet just above the wound.
Place the client in a modified Trendelenburg position.
Apply pressure directly to the wound.
Settle the client in a reclining position.
The Correct Answer is C
This is the first step in controlling bleeding and preventing hematoma formation 1.
Applying direct pressure to the wound with a sterile gauze or a clean cloth can help stop the bleeding 2.
Choice A is not the best answer because a tourniquet should only be used as a last resort to control life-threatening bleeding from a limb 2.
Choice B is not the best answer because placing the client in a modified Trendelenburg position is not necessary for this situation.
Choice D is not the best answer because settling the client in a reclining position is not necessary for this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“Patient’s platelets 100,000.” A nurse should report a low platelet count to the provider because it may indicate heparin-induced thrombocytopenia (HIT), a serious complication of heparin therapy.
Choice B is not correct because a Prothrombin time (PT) of 12 seconds is within the normal range and does not need to be reported.
Choice C is not correct because Thrombin time (TT) is not typically used to monitor heparin therapy.
Choice D is not correct because a Hematocrit of 35% is within the normal range and does not need to be reported.
Correct Answer is ["50"]
Explanation
To calculate the flow rate in gtt/min, you need to divide the total volume of the IV fluid (400 mL) by the total infusion time in minutes (8 hours x 60 minutes/hour = 480 minutes) and then multiply by the drop factor of the manual IV tubing (60 gtt/mL).
This gives you a flow rate of (400 mL / 480 minutes) x 60 gtt/mL = 50 gtt/min.
The other choices are not answers because they are not provided in the question.
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