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 B
Explanation
A. Preparing a 60-mL syringe with saline may be necessary for gastric lavage but is not the first action.
B. For an unconscious patient who has ingested a significant quantity of lorazepam, securing the airway is the most critical first step to prevent aspiration and ensure the patient can breathe. Therefore, the nurse should assist with intubation of the patient.
C. The initial step is to ensure that the client’s airway is secured through intubation before administration of activated charcoal.
D. Inserting a large-bore orogastric tube may be necessary for gastric lavage but typically follows administration of activated charcoal.
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.
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