A nurse is caring for an adolescent in the outpatient dermatologist's office.

Exhibits

Complete the following sentence by using the lists of options.

A nurse is providing education today on the newly-prescribed medication. The nurse recommends the adolescent notify the provider immediately if 

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or

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occurs during therapy.

A. Apply a transparent dressing to the wound. Transparent dressings are not appropriate for active bleeding as they are too thin and do not absorb blood or provide compression to control hemorrhage.
B. Irrigate the wound with sterile water. Wound irrigation is not a priority when a client is actively bleeding. Controlling the bleeding takes precedence over cleaning the wound.
C. Apply direct pressure to the wound with thick dressing material. Direct pressure is the first-line intervention to control external bleeding. Applying firm pressure with a thick dressing helps compress the blood vessels and minimize blood loss.
D. Tie a tourniquet around the leg distal to the wound. A tourniquet should be applied proximal (above) the wound if needed and only after direct pressure fails to control the bleeding. Applying it distal is ineffective and potentially harmful.

A. A client who has a forehead wound that is bleeding copiously. Although bleeding may appear dramatic, most scalp wounds bleed heavily and can be controlled with pressure. This is not immediately life-threatening if the client is stable.
B. A client who has a compound fracture of the femur and is crying in pain. This is a serious injury with risk for blood loss and infection, but the client is alert and stable enough to express pain, suggesting less immediate neurologic risk than other clients.
C. A client who was unconscious at the scene and now reports diplopia and nausea. This client likely has a head injury with signs of increased intracranial pressure or concussion (diplopia = double vision, nausea, and prior loss of consciousness). These are neurological red flags and require immediate evaluation to prevent deterioration.
D. A client who has several missing teeth and a swollen, ecchymotic upper lip. While painful and concerning, oral trauma without airway compromise is less urgent than potential brain injury.