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
Protamine is a medication that can be used to reverse the effects of heparin in the event of an overdose.
It binds to heparin and neutralizes its anticoagulant effects.
Choice B is not correct because glucagon is used to treat low blood sugar, not heparin overdose.
Choice C is not correct because oxygen is not a medication and is not used to treat heparin overdose.
Choice D is not correct because insulin is used to lower high blood sugar levels, not to treat heparin overdose.
Correct Answer is C
Explanation
The nurse should set the flow rate to deliver 40 gtts/min.
This can be calculated by multiplying the infusion rate (120 mL/hr) by the drop factor (60 gtt/mL) and then dividing by the number of minutes in an hour (60 min/hr): (120 mL/hr) * (60 gtt/mL) / (60 min/hr) = 120 gtt/min
Choice A is not the best answer because setting the flow rate to deliver 20 gtts/min would not provide the desired infusion rate of 120 mL/hr.
Choice B is not the best answer because setting the flow rate to deliver 30 gtts/min would not provide the desired infusion rate of 120 mL/hr.
Choice D is not the best answer because setting the flow rate to deliver 50 gtts/min would provide a higher infusion rate than desired.
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