A patient is brought to the ED by a friend who states that a tree fell on the patient’s leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)
Elevating the site to limit the accumulation of fluid in the interstitial spaces
Performing a fasciotomy
Applying a clean dressing to protect the wound
Inserting an indwelling catheter
Splinting the wound in a position of rest to prevent motion
Correct Answer : C,E
A. Elevating the site is incorrect because in crush injuries, elevation can worsen ischemia by reducing arterial perfusion.
B. Performing a fasciotomy is incorrect because this is a surgical procedure that must be performed by a physician when compartment syndrome is diagnosed.
C. Applying a clean dressing to protect the wound is correct as it prevents contamination and infection.
D. Inserting an indwelling catheter is incorrect unless there is concern for shock or fluid balance issues, which are not immediately indicated in the question.
E. Splinting the wound in a position of rest to prevent motion is correct as immobilization reduces pain and prevents further injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A high fat, low carbohydrate formula is most appropriate for patients with poorly controlled diabetes mellitus, as it helps stabilize blood glucose levels while still providing necessary nutrition.
B. A concentrated calorie formula may not be appropriate for this patient as it could lead to hyperglycemia due to increased glucose intake.
C. Whole proteins and glucose polymers might increase the glucose load and exacerbate poor blood sugar control.
D. While low sodium is important for many conditions, it is not the primary concern for managing poorly controlled diabetes mellitus in the context of enteral nutrition.
Correct Answer is B
Explanation
A. Discontinuing the tube feeding and transitioning to parenteral nutrition is not the first action, as the residual volume may be manageable with additional interventions.
B. A residual volume of 200 mL is above the usual threshold, so the nurse should stop the feeding, wait, and recheck the residual to assess if it improves.
C. While positioning can help gastric emptying, the immediate action should be to stop the feeding and reassess before continuing.
D. Continuing the feeding without rechecking the residual volume would be premature, as the volume is higher than expected, potentially increasing the risk of aspiration.
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