A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching?

Apply a tourniquet to the affected extremity.

Raise the affected extremity above the level of the heart.

Start two large bore IV's

Apply ice to the bite area.

Answer and Explanation

The Correct Answer is C

A. Applying a tourniquet is not recommended as it can cause tissue damage.
B. The affected extremity should be kept at or below the level of the heart to slow venom spread, not raised.
C. Starting two large-bore IVs is important for fluid resuscitation and administration of antivenom if needed.
D. Applying ice is not advised as it can worsen tissue injury.

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Correct Answer is D

Explanation

A. Initiating fluid resuscitation is a vital component of burn management during the resuscitation phase, but it follows airway stabilization in priority.
B. Inserting an indwelling urinary catheter is important for monitoring fluid output and kidney function, but it is not the immediate priority.
C. Pain management is essential in burn care, but it is not the most urgent intervention during the initial phase of care.
D. According to the ABCs of emergency care (Airway, Breathing, Circulation), securing the airway is always the first priority, especially in clients with burns to the chest and upper body where airway edema and inhalation injury are likely.

A. No further intervention required. B. Remove the nasal packing and dressing. C. Perform a Halo test with the drainage. D. Encourage client to blow their nose.

Correct Answer is C

Explanation

A. Further assessment is needed when clear drainage is noted to rule out cerebrospinal fluid (CSF) leak.
B. Removing nasal packing can increase the risk of bleeding and should not be done without a provider’s order.
C. Performing a Halo test helps identify if the drainage contains CSF, which indicates a possible leak and requires immediate attention.
D. Encouraging the client to blow their nose could increase intracranial pressure and worsen the leak.

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A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?

Correct Answer is D

Explanation

A nurse is caring for a client who is 24 hours postoperative after a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

Correct Answer is C

Explanation

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