A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?
Remove both of the elastic bandages from the leg
Obtain a prescription for pain medication.
Discharge the client.
Obtain a prescription for the appropriate anti-venom.
The Correct Answer is D
A. Removing the elastic bandages could lead to rapid systemic absorption of venom, increasing the severity of envenomation.
B. Pain management is important but secondary to administering anti-venom in cases of snakebite.
C. Discharging the client without proper evaluation and treatment for potential envenomation could lead to serious complications.
D. Administering the appropriate anti-venom is critical to neutralize venom effects and prevent worsening of symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
To calculate the infusion rate in mL/hr for administering ceftriaxone 1 g via intermittent IV bolus over 30 minutes, you would use the formula: (Total Volume in mL / Time in hours) = Rate in mL/hr. In this case, the total volume of the solution is 100 mL, and the time frame is 0.5 hours (since 30 minutes is half an hour). Therefore, the calculation would be 100 mL / 0.5 hours = 200 mL/hr.
Correct Answer is []
Explanation
Potential Condition:
Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.
Actions to Take:
Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.
Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.
Parameters to Monitor:
Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.
Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.
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