During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
Send blood to the lab for a complete blood count.
Finish the airway, breathing, circulation, disability survey.
Assess further for a cause of the decreased circulation,
Start normal saline fluid infusion with a large bore IV line.
The Correct Answer is C
A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reviewing the client's medical record is important for understanding their health status but is not directly related to investigating an injury claim at the workplace.
B. Reviewing the workplace procedures and protocols manual is crucial to understanding the standards and practices relevant to the injury claim.
C. The Occupational Safety and Health Act provides guidelines and regulations for workplace safety but does not provide specific details about individual injury claims.
D. The client's attendance record at health and safety seminars may be informative but is less directly relevant to investigating the injury claim compared to reviewing workplace protocols.
Correct Answer is D
Explanation
A. Removing the elastic bandages could lead to rapid systemic absorption of venom, increasing the severity of envenomation.
B. Pain management is important but secondary to administering anti-venom in cases of snakebite.
C. Discharging the client without proper evaluation and treatment for potential envenomation could lead to serious complications.
D. Administering the appropriate anti-venom is critical to neutralize venom effects and prevent worsening of symptoms.
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