A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Place the client in a modified Trendelenburg position.

Apply a tourniquet just above the wound.

Start two large-bore IV catheters.

Apply pressure directly to the wound.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Placing the client in a modified Trendelenburg position is not the first intervention for a client with a deep laceration and heavy bleeding. This position involves tilting the patient with the head lower than the feet and is typically used to improve venous return in certain situations, such as hypovolemic shock. However, for a bleeding wound, the priority is to control the bleeding itself.

Choice B rationale:

Applying a tourniquet just above the wound is a drastic measure and is generally not the first intervention for controlling bleeding. Tourniquets are used when direct pressure and other methods are unsuccessful, as they can lead to complications such as tissue damage and ischemia if not used correctly.

Choice C rationale:

Starting two large-bore IV catheters is important for fluid resuscitation in cases of significant bleeding. However, it is not the first intervention. Directly controlling the bleeding takes precedence to prevent further blood loss.

Choice D rationale:

Applying pressure directly to the wound is the correct answer. This is the initial and immediate action to take when dealing with a heavily bleeding wound. Applying pressure helps to stem the bleeding by promoting clot formation and reducing blood loss. It is a vital step in managing the client's condition and preventing further deterioration.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.

Choice B rationale:

This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.

Choice C rationale:

This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.

Choice D rationale:

This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.

Choice E rationale:

This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.

A. Only fresh frozen plasma should be transfused to the client. B. An immediate blood transfusion should be started due to the client's condition. C. The client should be asked to decide about the blood transfusion. D. The client's family should be notified immediately of the situation.

Correct Answer is C

Explanation

Choice A rationale:

Fresh frozen plasma (FFP) is a component of blood used to replace clotting factors and is typically indicated for specific medical conditions like bleeding disorders or massive transfusions. In this case, the client requires red blood cells due to significant blood loss, so FFP alone is not the appropriate choice.

Choice B rationale:

Initiating an immediate blood transfusion without the client's consent is not ethically appropriate, especially considering the client's religious beliefs as a Jehovah's Witness. Respecting the client's autonomy and religious convictions is important.

Choice C rationale:

Asking the client to decide about the blood transfusion is the correct course of action. Since the client is able to respond to questions appropriately, they should be informed about their condition, the need for a blood transfusion, and the potential risks and benefits. This respects the client's autonomy while ensuring they have the necessary information to make an informed decision.

Choice D rationale:

Notifying the client's family immediately is not the best initial action. While involving the family is important, the client's own decision about the blood transfusion should take precedence, especially when they are conscious and able to make decisions for themselves.

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A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.).

Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is C

Explanation

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