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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. A patient with anaphylactic reaction may have unpredictable clinical course and require immediate interventions, which could affect the stability of the roommate.
B. A patient with viral pneumonia poses a lower risk of infection transmission to an immunocompromised patient with acute organ rejection compared to other options.
C. Graft-versus-host disease indicates an immunocompromised state and poses infection risks, similar to acute rejection patients.
D. Second degree burns also pose infection risks and would not be suitable for a roommate of a patient with acute organ rejection.

A. Check the IV site for bleeding every 8 hr B. Obtain a rectal temperature every 8 hr. C. Check the client for proteinuria. D. Limit, IM injections.

Correct Answer is D

Explanation

A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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