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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. In January, WBC count was 5,500/mm3. In February, it decreased to 4,500/mm3. A decrease in WBC count indicates an improvement in the client's condition, suggesting a potential reduction in chemotherapy-related immunosuppression.
B. In January, platelet count was 150,000/mm3. In February, it decreased slightly to 140,000/mm3. The slight decrease in platelet count may not necessarily indicate improvement but is relatively stable.
C. In January, the client reported bleeding episodes from mouth ulcers. In February, the client reports no bleeding episodes. The absence of bleeding episodes indicates improvement in oral mucosal health and potential effectiveness of interventions.
D. In January, the oral mucosa was inflamed. In February, there is noted improvement with less inflammation. Improved oral health with reduced inflammation indicates a positive response to interventions and potentially better oral hygiene practices.
E. The client experienced weight loss of 1.5 kg (3.3 lb) from January to February. Weight loss may indicate ongoing challenges with nutrition despite efforts to increase food intake and manage symptoms.
Correct Answer is D
Explanation
A. Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Keeping blood pressure equipment in the client's room is necessary but does not directly address infection control, which is critical in stem cell transplant recipients.
D. Placing the client in a negative airflow room is crucial to reduce the risk of infections, which are a major concern in immunocompromised clients undergoing stem cell transplantation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.