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A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?
- A. Elevate the limb and apply ice.
- B. Apply a tourniquet just below the elbow.
- C. Apply direct pressure over the wound.
- D. Clean the wound.
Correct Answer: C
Rationale: Applying direct pressure is the first-line intervention to control profuse bleeding, stopping or reducing blood loss immediately.
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A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: Using the Rule of Nines, the anterior trunk is 18%, each upper limb (upper arm) is 4.5%, and each forearm is 2.25%. The calculation yields 24.75% for anterior and 6.75% for posterior, totaling 31.5% of body surface area burned.
A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?
- A. Elevate the limb and apply ice.
- B. Apply a tourniquet just below the elbow.
- C. Apply direct pressure over the wound.
- D. Clean the wound.
Correct Answer: C
Rationale: Applying direct pressure is the first-line intervention to control profuse bleeding, stopping or reducing blood loss immediately.
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
- A. Keep family members aware of his condition.
- B. Talk with the client during wound care.
- C. Rotate nursing staff so he can have varied interactions.
- D. Assign assistive personnel to keep his room neat and clean.
Correct Answer: B
Rationale: Talking with the client during wound care builds trust, provides emotional support, and helps cope with pain and stress. Other options are less directly supportive emotionally.
A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
- A. 4 hr
- B. 2 hr
- C. 8 hr
- D. 6 hr
Correct Answer: A
Rationale: The total infusion time for packed RBCs should not exceed 4 hours to minimize the risk of bacterial growth in the blood product, which can lead to sepsis and other serious complications. Infusing beyond 4 hours increases this risk significantly.
A nurse is providing dietary teaching to a client who has a new onset of vitamin B12 deficiency. Which of the following foods should the nurse encourage the client to include in their diet?(Select All that Apply)
- A. Steak
- B. Low fat milk
- C. Grilled salmon
- D. Green leafy vegetables
- E. Scrambled eggs
Correct Answer: A,B,C,E
Rationale: Steak, milk, salmon, and eggs are high in vitamin B12, suitable for addressing deficiency. Green leafy vegetables are not significant sources of B12, which is primarily found in animal products.