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 D

Explanation

Choice A rationale:

Pneumonia is not likely to be the correct answer. Pneumonia is often characterized by productive cough, fever, chest pain, and increased tactile fremitus due to consolidation of lung tissue. The presence of barrel chest, decreased tactile fremitus, and hyperresonant percussion sounds is not consistent with pneumonia.

Choice B rationale:

Atelectasis is not the most likely option. Atelectasis refers to collapsed or partially collapsed lung tissue, which can lead to decreased breath sounds, dullness to percussion, and decreased tactile fremitus. The symptoms mentioned in the scenario, such as prolonged expiration, wheezes, and barrel chest, are not indicative of atelectasis.

Choice C rationale:

Pleural effusion is not the most suitable choice. Pleural effusion usually presents with decreased breath sounds, dullness to percussion, and decreased tactile fremitus over the affected area due to fluid accumulation in the pleural space. The hyperresonant percussion sounds and the presence of wheezes and rhonchi do not align with pleural effusion.

Choice D rationale:

Emphysema is the most likely disorder based on the given symptoms. Barrel chest (increased anterior-posterior chest diameter), limited lung expansion, decreased tactile fremitus, hyperresonant percussion sounds, prolonged expiration, wheezes, and rhonchi are characteristic findings of emphysema. This condition involves damage to the alveoli and their supporting structures, leading to air trapping, reduced lung elasticity, and obstructed airflow. The patient's use of accessory muscles to breathe further suggests a chronic obstructive pulmonary disease (COPD) like emphysema.

A. Offer a glass of water to the patient. B. Monitor the patient for signs and symptoms of shock. C. Place moist sterile gauze over the site. D. Gently place the organs back. E. Contact the patient's Surgeon.

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

Explanation

Choice A rationale:

Offering a glass of water to the patient is not a priority action when dealing with a surgical incision that eviscerates. This situation requires immediate intervention to prevent complications related to the evisceration.

Choice B rationale:

Monitoring the patient for signs and symptoms of shock is crucial in this scenario. Evisceration, the protrusion of organs from a surgical incision, can lead to significant blood loss, which may result in shock. Signs of shock include hypotension, tachycardia, pallor, diaphoresis, and altered mental status.

Choice C rationale:

Placing moist sterile gauze over the site is appropriate to prevent the exposed organs from drying out and becoming further damaged. It also helps to reduce the risk of infection. Moist sterile gauze helps maintain a sterile environment and prevents the organs from being exposed to contaminants.

Choice D rationale:

Gently placing the organs back into the abdominal cavity is not within the nurse's scope of practice. This action requires surgical intervention by a healthcare provider. The nurse's role is to provide immediate first aid and notify the surgeon.

Choice E rationale:

Contacting the patient's surgeon is essential. Evisceration is a surgical emergency, and the surgeon needs to be informed promptly to make decisions regarding further interventions. The patient may require emergency surgery to address the evisceration and prevent complications.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse on the Medical-Surgical unit is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.).

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

Explanation

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