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 D
Explanation
“Inject the medication into the abdomen above the level of the iliac crest.” When administering heparin subcutaneously, it is appropriate to inject the medication into the abdomen above the level of the iliac crest 1.
Choice A is not correct because a 1-inch needle may be too long for subcutaneous injection.
A shorter needle, such as a 3/8 to 5/8 inch needle, is typically used for subcutaneous injections.
Choice B is not correct because a 22-gauge needle may be too large for subcutaneous injection.
A smaller gauge needle, such as a 25- or 27-gauge needle, is typically used for subcutaneous injections.
Choice C is not correct because massaging the injection site after administering heparin can increase the risk of bruising and should be avoided.
Correct Answer is B
Explanation
NPH insulin has an onset of action of about 1 to 2 hours, peaks in 4 to 12 hours, and lasts up to 24 hours. Given the administration at 0700, the onset of action would typically occur between 0800 and 0900. Hypoglycemia is most likely to occur during the onset or peak periods due to the insulin's glucose-lowering effect.
Among the options:
- A. 0715: Too early, as NPH insulin's onset is not within 15 minutes.
- B. 0800: Within the onset window (1 hour after administration), making it a plausible time to observe for hypoglycemia.
- C. 0900: Also within the onset window (2 hours after administration), another reasonable time to monitor.
- D. 1000: Slightly beyond the typical onset but still early in the action profile, where hypoglycemia could occur if glucose levels drop.
Since the question asks for the time to observe for hypoglycemia caused by the onset, the earliest time within the onset window is most appropriate. Thus, B. 0800 is the best answer, as it aligns with the start of NPH insulin’s onset period.
Final Answer: B. 0800
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