A nurse working in an emergency department is caring for a client who has third-degree frostbite to both lower extremities. The nurse should take which of the following actions?

Massage the legs.

Apply dry heat to the legs.

Elevate the legs.

Immerse the legs in cold water.

Answer and Explanation

The Correct Answer is C

A. Massage the legs: This is incorrect. Massage is contraindicated as it can cause further tissue damage and is not appropriate for frostbite.
B. Apply dry heat to the legs: This is incorrect. Dry heat can exacerbate tissue damage. Rewarming should be done using controlled, warm water immersion, not dry heat.
C. Elevate the legs: This is correct. Elevating the legs helps reduce swelling and can prevent further tissue damage. However, rewarming should be done carefully in a controlled environment.
D. Immerse the legs in cold water: This is incorrect. Immersing in cold water would worsen the frostbite. Rewarming should be done using warm (not hot) water, ideally at 37-39°C (98.6-102.2°F), for effective treatment.

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Correct Answer is A

Explanation

A. "I can detect the presence of carbon monoxide by a metallic odor." This is incorrect. Carbon monoxide is odorless, colorless, and tasteless, making it undetectable by smell.
B. "A high concentration of carbon monoxide can cause unconsciousness." This is correct. High levels of carbon monoxide can lead to serious symptoms including loss of consciousness.
C. "Breathing in carbon monoxide can cause headaches and nausea." This is correct. Symptoms of carbon monoxide poisoning include headaches, nausea, and dizziness.
D. "Leaky gas or oil furnaces can cause carbon monoxide poisoning." This is correct. Faulty or leaky heating systems can be a source of carbon monoxide exposure.

A. Initiate intravenous (IV) access for fluid replacement. B. Place the client's arm in a dependent position. C. Apply pressure directly to the wound. D. Apply a tourniquet just below the level of the shoulder.

Correct Answer is C

Explanation

A. Initiate intravenous (IV) access for fluid replacement. This is important for managing shock or significant blood loss, but it is not the first priority in managing severe bleeding.
B. Place the client's arm in a dependent position. This would not be appropriate for severe bleeding and does not control hemorrhage effectively.
C. Apply pressure directly to the wound. This is correct. Direct pressure is the immediate and essential step to control bleeding in a severe wound. It helps to stabilize the clot and reduce blood loss.
D. Apply a tourniquet just below the level of the shoulder. This is not the first intervention. A tourniquet is used if direct pressure does not control severe bleeding and should be applied above the wound, not below.

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A nurse working in an emergency department is caring for a client who has third-degree frostbite to both lower extremities. The nurse should take which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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