A nurse in an emergency department is caring for a patient with a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse take?

Apply a tourniquet just below the elbow.

Elevate the limb and apply ice.

Clean the wound.

Apply pressure above the wound.

Answer and Explanation

The Correct Answer is B

Choice A reason: Applying a tourniquet just below the elbow is not recommended as the first line of action for a deep laceration unless there is life-threatening hemorrhaging that cannot be controlled by direct pressure. Tourniquets are used as a last resort because they can cause tissue damage.

Choice B reason: Elevating the limb and applying ice can help reduce bleeding and swelling. Elevation uses gravity to help reduce blood flow to the injury, and the cold from the ice constricts blood vessels, further helping to control bleeding and reduce swelling.

Choice C reason: Cleaning the wound is important, but it should not be the first action taken. The initial focus should be on stopping the bleeding. Once bleeding is controlled, the wound can be cleaned to prevent infection.

Choice D reason: Applying pressure directly to the wound with a clean cloth or bandage is the first step in controlling bleeding. However, the question specifies applying pressure above the wound, which would not be effective in controlling bleeding from the wound itself.

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Correct Answer is C

Explanation

Choice A reason: Physical therapy may be prescribed postoperatively to aid in recovery, but it does not directly interfere with the function of a pacemaker.

Choice B reason: Checking serum cardiac enzyme levels is a common practice after heart surgery to assess for any damage to the heart muscle, which would not typically require clarification in the context of pacemaker insertion.

Choice C reason: An MRI of the chest should be clarified with the healthcare provider because MRI can interfere with pacemaker function. Patients with pacemakers are generally advised to avoid MRI unless the pacemaker is Incompatible, due to the risk of the magnetic field affecting the device's operation.

Choice D reason: A low sodium diet may be recommended for patients with heart conditions to manage blood pressure and fluid retention, but it is not directly related to the care of a pacemaker.

A. Urine specific gravity of 1.020 B. Serum sodium of 165 mEq/L C. Hematocrit of 48% D. Blood urea nitrogen (BUN) of 12 mg/dL

Correct Answer is A

Explanation

Choice A reason: Urine specific gravity measures the kidney's ability to concentrate urine. A normal range is typically 1.005–1.030. A value of 1.020 indicates adequate hydration and suggests that the patient is responding well to IV fluid therapy.

Choice B reason: Serum sodium levels reflect electrolyte balance. The normal range is 135–145 mEq/L. A level of 165 mEq/L is significantly elevated, indicating hypernatremia, which could be a sign of inadequate hydration and not a positive response to treatment.

Choice C reason: Hematocrit represents the proportion of blood volume occupied by red blood cells. Normal ranges are 38.3–48.6% for men and 35.5–44.9% for women. A hematocrit of 48% is at the upper limit of normal and does not specifically indicate the effectiveness of dehydration treatment.

Choice D reason: Blood urea nitrogen (BUN) levels can indicate renal function and hydration status. The normal range is 7–20 mg/dL. A BUN of 12 mg/dL is within the normal range and does not specifically reflect the patient's response to IV fluids for dehydration.

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A nurse in an emergency department is caring for a patient with a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse take?

Nursing Test Bank

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