A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects the snake to be venomous. Which of the following interventions should the nurse take?
Place the extremity in a dependent position.
Administer a corticosteroid.
Apply a tourniquet just above the elbow
Apply an ice pack to the site of the bite.
The Correct Answer is A
A. Place the extremity in a dependent position: The extremity should be placed lower than the heart to slow venom spread. Elevating the limb can increase circulation of the venom, worsening the situation. A dependent position helps to reduce venom movement.
B. Administer a corticosteroid: Corticosteroids are not used for snake bites. The primary treatment involves antivenom and supportive care. Corticosteroids can suppress the immune response and are ineffective for venomous bites.
C. Apply a tourniquet just above the elbow: Tourniquets can cause further tissue damage and concentrate venom. They are not recommended for snake bites and can worsen outcomes by restricting circulation and causing more harm.
D. Apply an ice pack to the site of the bite: Applying ice slows circulation, which could worsen the spread of venom. It should not be used for snake bites, as it delays proper treatment and does not help in venom management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increase in the heart rate from 88 to 90/min: A heart rate increase of 2/min is not significant to indicate hypovolemic shock. In the early stages of hypovolemic shock, a more pronounced increase in heart rate is expected as a compensatory mechanism for low blood volume.
B. Increase in the temperature from 99.5°F to 100°F: A slight increase in temperature is common postoperatively and is generally not indicative of hypovolemic shock. A more concerning sign would be a fever that is significantly elevated or a rapid temperature change in combination with other symptoms.
C. Decrease in the respiratory rate from 20 to 16/min: A decrease in respiratory rate is not typically a sign of hypovolemic shock. In shock, respiratory rate often increases as the body compensates for decreased oxygen perfusion.
D. Decrease in the urinary output from 50 mL to 30 mL per hour: As the body experiences decreased perfusion due to blood loss, the kidneys are less able to filter and excrete urine. A decrease in urinary output indicates poor renal perfusion, which is a sign of shock.
Correct Answer is A
Explanation
A. Asystole: Asystole is defined as the complete absence of electrical and mechanical cardiac activity. The EKG strip displays a flatline, indicating no ventricular depolarization or contraction, which is the hallmark of asystole. This rhythm is a non-shockable cardiac arrest rhythm.
B. Sinus Tachycardia: Sinus tachycardia is a regular rhythm with a heart rate greater than 100 bpm, characterized by clear P waves and QRS complexes. This is clearly not present in the given flatline strip.
C. Sinus Bradycardia: Sinus bradycardia is a regular rhythm with a heart rate less than 60 bpm, characterized by clear P waves and QRS complexes.
D. Supraventricular Tachycardia (SVT): SVT is a rapid rhythm, typically 150-250 bpm, with narrow QRS complexes and often obscured P waves.
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