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
The nurse should include in the teaching that the client should use a soft-bristled toothbrush.
Heparin is an anticoagulant that decreases the clotting ability of the blood 1.
Using a soft-bristled toothbrush can help prevent bleeding of the gums while brushing teeth.
Choice B is incorrect because heparin should not be injected deep into the thigh muscle.
Instead, it should be given subcutaneously (under the skin) 2.
Choice C is incorrect because black and tarry stools are not an expected side effect of heparin.
Choice D is incorrect because easy bruising does not indicate that the medication is effective.
Instead, easy bruising may be a side effect of heparin and should be reported to the healthcare provider 1.
Correct Answer is ["100"]
Explanation
The nurse should set the IV flow rate to deliver 100 gtt/min.
To calculate the flow rate in gtt/min, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) ÷ Time (min) = Flow rate (gtt/min).
Plugging in the values from the question: (100 mL x 60 gtt/mL) ÷ 60 min = 100 gtt/min.
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