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 C
Explanation
A. Sodium Bicarbonate is incorrect as it is not a first-line treatment for VF. It may be considered in cases of severe acidosis or hyperkalemia.
B. Amiodarone is incorrect as it is used as an antiarrhythmic, but epinephrine is administered first during cardiac arrest to increase perfusion.
C. Epinephrine is correct because it is the first-line drug given in ventricular fibrillation that persists after defibrillation. It increases coronary and cerebral perfusion and enhances the effectiveness of subsequent defibrillation attempts.
D. Lidocaine is incorrect as it is an antiarrhythmic that may be considered after epinephrine and amiodarone, but it is not the first choice.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Blank 1
Prepare for defibrillation: The client is unresponsive and has ventricular tachycardia. This indicates a life-threatening arrhythmia. If a patient with VTach is pulseless, the treatment is defibrillation.
Blank 2
Vtach (Ventricular tachycardia): The ECG tracing shows a rapid, wide-complex tachycardia, which is the hallmark of ventricular tachycardia.
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