During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
Send blood to the lab for a complete blood count.
Finish the airway, breathing, circulation, disability survey.
Assess further for a cause of the decreased circulation,
Start normal saline fluid infusion with a large bore IV line.
The Correct Answer is C
A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["21"]
Explanation
Total volume in mL: 3000 mL
Time in hours: 24 hours
Total volume to be infused in minutes: We need to convert hours to minutes. There are 60 minutes in 1 hour. Therefore, total time in minutes = 24 hours * 60 minutes/hour = 1440 minutes
Drop factor: 10 gtt/mL
Rate in mL/min: We can divide the total volume (mL) by the total time (minutes) to find the flow rate in mL per minute. Rate (mL/min) = 3000 mL / 1440 minutes = 2.08 mL/min (rounded to two decimal places)
Rate in gtt/min: To find the rate in gtt/min, multiply the rate in mL/min by the drop factor. Rate (gtt/min) = 2.08 mL/min * 10 gtt/mL = 20.8 gtt/min
Rounding the answer to the nearest whole number: 20.8 gtt/min rounds off to the nearest whole number to 21 gtt/min.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}
Explanation
- This prescription helps maintain oral hygiene and comfort, which is important during chemotherapy to prevent and manage mucositis.
- Routine daily temperature checks may not be necessary unless there are specific concerns about infection or fever.
- Placing the client in a private room can reduce the risk of infection, which is crucial due to the client's immunocompromised state from chemotherapy.
- Unless there is a specific medical indication (e.g., urinary retention), inserting an indwelling urinary catheter increases the risk of infection, which should be minimized in an immunocompromised client.
- Droplet precautions are typically used for respiratory infections transmitted by large droplets. Lung cancer itself does not typically require droplet precautions unless there is an active respiratory infection.
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