In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake?

Apply ice to the site of the wound

Extract venom by sucking the wound

Apply a tourniquet to the affected arm

Immobilize the extremity at the level of the heart

Answer and Explanation

The Correct Answer is D

A. Although it may seem intuitive to cool the bite site, ice is not recommended in snakebite management. Cooling can damage local tissue and does not slow the systemic spread of venom. Applying ice can actually worsen tissue injury and delay healing.

B. Techniques such as suction or cutting the bite site are outdated and ineffective. Studies show that attempting to extract venom orally does not remove enough venom to impact outcomes and increases the risk of infection or further tissue damage.

C. Tourniquets are contraindicated because they can restrict blood flow, leading to tissue ischemia, necrosis, and permanent damage. Additionally, sudden release of a tourniquet may cause a surge of venom into the circulation, worsening systemic toxicity.

D. Immobilization helps slow lymphatic spread of venom, reducing systemic absorption. Keeping the limb at or slightly below heart level prevents unnecessary venom circulation while avoiding excessive swelling that would occur if the limb were elevated above the heart. The patient should remain calm and limit movement to reduce venom distribution. Emergency medical services should be contacted immediately for assessment, antivenom administration if indicated, and monitoring of vital signs and systemic effects.

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Correct Answer is D

Explanation

A. This flow rate is within the normal range (10–15 L/min) for a nonrebreather mask, which is sufficient to maintain partial inflation of the reservoir bag and deliver high-concentration oxygen.

B. This is normal function. The exhalation ports allow carbon dioxide to escape during exhalation while preventing rebreathing of exhaled air.

C. This is expected and appropriate. Closing the exhalation ports during inhalation ensures the patient draws oxygen from the reservoir bag rather than room air.

D. A collapsed bag indicates that the patient is not receiving adequate high-concentration oxygen, which can quickly lead to hypoxemia and respiratory compromise. Causes may include low oxygen flow, a loose mask, or tubing obstruction. Immediate intervention is required to check the oxygen source, ensure proper mask fit, inspect tubing for kinks or disconnections, and monitor oxygen saturation.

A. localized infiltrate B. enlargement of the heart C. white-out infiltrates bilaterally D. hyperinflation of lungs

Correct Answer is C

Explanation

A. Localized infiltrates indicate a focal process, such as bacterial pneumonia or aspiration in a single lobe. ARDS affects the lungs diffusely, so a localized pattern would not support the diagnosis.

B. Cardiomegaly is associated with cardiogenic pulmonary edema, where heart failure causes fluid accumulation in the lungs. In ARDS, the pulmonary edema is non-cardiogenic, and the heart size is typically normal.

C. In ARDS, the alveoli fill with fluid, protein, and inflammatory cells, causing widespread opacification on chest x-ray. This appears as bilateral, patchy, or confluent “white-out” infiltrates, indicating severe alveolar involvementand impaired oxygenation. These findings correlate with the patient’s rapidly worsening hypoxemia and respiratory distress.

D. Hyperinflation is characteristic of obstructive airway diseaseslike COPD or asthma, where air is trapped in the lungs. In ARDS, the lungs are stiff and noncompliant, so hyperinflation does not occur.

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In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake?

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Naxlex Comprehensive Predictor Exams

Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately?

Correct Answer is D

Explanation

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?

Correct Answer is C

Explanation

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