Choice A Reason: The nurse should apply direct pressure to the wound with a clean cloth or gauze to control bleeding as the first priority. This action can reduce blood loss and prevent shock.

Choice B Reason: The nurse should elevate the leg above the level of the heart after applying direct pressure to the wound. This action can help reduce swelling and bleeding by decreasing venous pressure.

Choice C Reason: The nurse should wrap the wound with a sterile dressing after controlling bleeding and elevating the leg. This action can protect the wound from infection and further injury.

Choice D Reason: The nurse should call for EMS if the bleeding is severe, does not stop, or if there are signs of shock, such as pale skin, rapid pulse, low blood pressure, or altered mental status. The nurse should not leave the client alone while waiting for EMS.

Choice A Reason: The nurse should splint the injured part in the position it was found to prevent further damage to the nerves, blood vessels, and soft tissues. The nurse should not attempt to realign or move the fractured bone unless there is no pulse distal to the injury.

Choice B Reason: The nurse should check for pulses, sensation, and movement distal to the injury before and after splinting to assess for neurovascular compromise. The nurse should report any changes or abnormalities to EMS or a health care provider.

Choice C Reason: The nurse should apply ice packs to the injured area for 20 minutes every hour to reduce pain, swelling, and inflammation. The nurse should wrap the ice pack in a cloth or towel to prevent frostbite.

Choice D Reason: The nurse should not manipulate or move the fractured bone to align it with the normal anatomy unless there is no pulse distal to the injury. This action can cause more damage and complications, such as bleeding, infection, nerve injury, or compartment syndrome.

Choice E Reason: The nurse should immobilize the joints above and below the fracture site to prevent movement of the fractured bone and reduce pain and muscle spasm. The nurse should use a rigid material, such as a board, cardboard, or metal rod, to splint the injured part.

Choice A Reason: The nurse should ask how many tablets did the client take and when did they take them to determine the dose and time of ingestion of acetaminophen. This information can help estimate the risk of toxicity and guide treatment options.

Choice B Reason: The nurse should not ask why did the client take acetaminophen tablets as this question may imply judgment or blame and discourage honest communication. The nurse should focus on assessing and managing the poisoning rather than exploring its cause.

Choice C Reason: The nurse should ask about allergies or medical conditions that may affect treatment decisions, but this question is not specific to acetaminophen poisoning. The nurse should prioritize obtaining information about the poisoning first.

Choice D Reason: The nurse should ask about symptoms or discomfort that may indicate toxicity or complications of acetaminophen poisoning, such as nausea, vomiting, abdominal pain, jaundice, or confusion. However, this question is less important than knowing how much and when acetaminophen was ingested.

Choice A Reason: The nurse should not expect the client to say that they feel much better after receiving epinephrine, as this medication may not reverse the anaphylactic reaction completely or prevent its recurrence. The nurse should continue to monitor the client for signs of respiratory distress, hypotension, or shock.

Choice B Reason: The nurse should expect the client to say that they feel very shaky and nervous after receiving epinephrine, as this medication is a sympathomimetic agent that stimulates the adrenergic receptors and causes side effects such as tremors, anxiety, palpitations, tachycardia, and hypertension. The nurse should reassure the client that these effects are normal and temporary.

Choice C Reason: The nurse should not expect the client to say that they feel very sleepy and tired after receiving epinephrine, as this medication is a stimulant that increases alertness and energy. The nurse should assess the client for hypoxia, hypoglycemia, or cerebral edema if they report feeling drowsy or lethargic.

Choice D Reason: The nurse should not expect the client to say that they feel very thirsty and dry after receiving epinephrine, as this medication does not cause dehydration or fluid loss. The nurse should assess the client for other causes of thirst or dry mouth, such as diabetes mellitus, diabetes insipidus, or anticholinergic medications.

Choice A Reason: The nurse should remove any clothing or jewelry from the chest area before attaching an AED to ensure good contact between the electrode pads and the skin. However, this action is not part of using an AED but rather preparing for its use.

Choice B Reason: The nurse should place one electrode pad on the upper right chest and one on the lower left chest when using an AED to deliver an electrical shock across the heart muscle and restore a normal rhythm. However, this action is not specific to using an AED but rather applying its electrode pads.

Choice C Reason: The nurse should press the shock button when instructed by the AED to deliver an electrical shock to the client if indicated by the device's analysis of the cardiac rhythm. This action is specific to using an AED and can be lifesaving for clients who have ventricular fibrillation or ventricular tachycardia.

Choice D Reason: The nurse should not continue chest compressions while the AED analyzes the rhythm or delivers a shock, as this can interfere with the device's function and accuracy. The nurse should stop chest compressions and ensure that no one is touching the client when prompted by the AED.