A young male adult walks into the emergency department (ED) holding a dead poisonous snake that bit him on his right calf within the last hour. After killing the snake, he tied a tablecloth about 4 inches (10 cm) above the bite. The client is now reporting numbness and tingling from the right knee to ankle. His heart rate is 123 beats/minute, respirations 28 breaths/minute, blood pressure 86/40 mm Hg, and oxygen saturation 94% on room air. Which intervention should the nurse implement?
Insert a large bore peripheral IV catheter.
Raise extremity above the heart.
Tighten the cloth around the leg.
Apply ice over the bite mark.
The Correct Answer is A
A. Insert a large bore peripheral IV catheter. The client is showing signs of shock (tachycardia, hypotension, tachypnea) likely due to envenomation and systemic venom effects. Rapid IV access is essential for fluid resuscitation, administration of antivenom, and management of shock. A large bore (18-gauge or larger) IV catheter allows for aggressive fluid therapy to maintain perfusion and prevent circulatory collapse.
B. Raise extremity above the heart. Elevating the limb can increase venom circulation, worsening systemic effects. Instead, the affected extremity should be kept at heart level to slow venom spread while ensuring adequate perfusion.
C. Tighten the cloth around the leg. Further tightening the makeshift tourniquet can lead to vascular compromise, ischemia, and increased local tissue damage. Modern guidelines discourage tourniquets as they do not prevent venom spread effectively and may worsen outcomes. The best approach is to loosen or remove restrictive bindings and keep the limb immobilized at heart level.
D. Apply ice over the bite mark. Cold therapy is contraindicated as it can worsen tissue damage by causing vasoconstriction, trapping venom, and increasing necrosis. Instead, the priority is IV access, fluid resuscitation, and preparing for possible antivenom administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respirations are shallow, labored, and 14 breaths/minute. A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
B. Has flaccid upper and lower extremities. Flaccid paralysis is an expected finding immediately after a high spinal cord injury due to spinal shock. While this condition requires ongoing monitoring, it is not an immediate life-threatening emergency like respiratory distress.
C. Blood pressure is 110/70 mm Hg and the apical heart rate is 68 beats/minute. These vital signs are within normal limits and do not indicate hemodynamic instability. Neurogenic shock, which can occur with high spinal injuries, typically presents with hypotension and bradycardia, but this client’s current BP and HR are stable.
D. Is unable to feel sensation in the arms and hands. Loss of sensation is expected with a cervical spinal cord injury due to nerve pathway disruption. While this finding is significant, it does not require immediate intervention compared to respiratory distress, which is the most urgent priority.
Correct Answer is A
Explanation
A. Muffled heart tones. Muffled heart tones in a client with blunt chest trauma are a key sign of cardiac tamponade, a life-threatening emergency where blood or fluid accumulates in the pericardial sac, preventing proper cardiac filling. This condition is part of Beck's triad (muffled heart tones, hypotension, and jugular vein distention) and requires immediate intervention, such as pericardiocentesis, to relieve pressure on the heart.
B. Bilateral sonorous wheezes. While wheezing indicates airway obstruction or bronchospasm, it is not as immediately life-threatening as cardiac tamponade. The nurse should continue monitoring and consider interventions like bronchodilators, but the priority is addressing muffled heart tones.
C. Widening pulse pressure. A widening pulse pressure (increased difference between systolic and diastolic BP) is typically associated with increased intracranial pressure (ICP) rather than blunt chest trauma. In chest trauma, a narrowing pulse pressure (e.g., in hypovolemic or obstructive shock) would be a greater concern.
D. Decreased urinary output. Reduced urine output may indicate shock or poor perfusion, but it is not the most urgent finding compared to muffled heart tones, which suggest impending cardiovascular collapse. While decreased urinary output should be addressed, cardiac tamponade takes priority due to the immediate risk of death.
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