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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
A. Docusate sodium suppositories are commonly used to prevent constipation, which is important postoperatively, especially if the client is experiencing decreased bowel sounds and reports feeling bloated.
B. Ice application can help reduce swelling (edema) in the scrotal and penile area, which is noted in the client's assessment. This can help alleviate discomfort and promote healing.
C. Antispasmodic medications can help manage bladder spasms, which are common postoperatively due to the presence of an indwelling urinary catheter and continuous bladder irrigation.
D. While changing positions is important to prevent complications like pressure ulcers and promote comfort, specifically placing the client in a sitting position while in bed may not be necessary and could potentially interfere with postoperative recovery and comfort.
E. Teaching the client how to use a leg bag for urinary drainage is important, especially if the client will be discharged with a catheter. This education ensures the client can manage their urinary drainage system effectively.
Correct Answer is ["21"]
Explanation
Total volume in mL: 3000 mL
Time in hours: 24 hours
Total volume to be infused in minutes: We need to convert hours to minutes. There are 60 minutes in 1 hour. Therefore, total time in minutes = 24 hours * 60 minutes/hour = 1440 minutes
Drop factor: 10 gtt/mL
Rate in mL/min: We can divide the total volume (mL) by the total time (minutes) to find the flow rate in mL per minute. Rate (mL/min) = 3000 mL / 1440 minutes = 2.08 mL/min (rounded to two decimal places)
Rate in gtt/min: To find the rate in gtt/min, multiply the rate in mL/min by the drop factor. Rate (gtt/min) = 2.08 mL/min * 10 gtt/mL = 20.8 gtt/min
Rounding the answer to the nearest whole number: 20.8 gtt/min rounds off to the nearest whole number to 21 gtt/min.
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