Summary
Summary ( 13 Questions)
A nurse is caring for a client who has an abdominal stab wound. The nurse notes that there is bright red blood spurting from the wound site. Which of the following actions should the nurse take? (Select all that apply.)
Choice A Reason: Applying direct pressure over the wound site with a sterile gauze pad can help control the bleeding by compressing the blood vessels. This is an appropriate action for arterial bleeding, which is bright red and spurts from a wound.
Choice B Reason: Elevating the client's legs above the level of the heart can help increase venous return and cardiac output, but it is not recommended for abdominal injuries, as it can increase intra-abdominal pressure and worsen bleeding or organ damage.
Choice C Reason: Applying ice packs around the wound site can help reduce inflammation and pain, but it is not recommended for bleeding wounds, as it can cause vasoconstriction and impair blood flow to the injured area.
Choice D Reason: Covering the wound site with an occlusive dressing can help prevent air from entering the abdominal cavity and causing a pneumoperitoneum, which can impair breathing and circulation. This is an appropriate action for penetrating wounds, such as stab wounds.
Choice E Reason: Checking the client's distal pulses frequently can help monitor the perfusion of the extremities and detect signs of shock or compartment syndrome. Shock is a condition in which there is inadequate tissue perfusion due to blood loss or other causes. Compartment syndrome is a condition in which there is increased pressure within a muscle compartment due to swelling or bleeding, which can compromise blood flow and nerve function.
Choice A Reason: Applying direct pressure over the wound site with a sterile gauze pad can help control the bleeding by compressing the blood vessels. This is an appropriate action for arterial bleeding, which is bright red and spurts from a wound.
Choice B Reason: Elevating the client's legs above the level of the heart can help increase venous return and cardiac output, but it is not recommended for abdominal injuries, as it can increase intra-abdominal pressure and worsen bleeding or organ damage.
Choice C Reason: Applying ice packs around the wound site can help reduce inflammation and pain, but it is not recommended for bleeding wounds, as it can cause vasoconstriction and impair blood flow to the injured area.
Choice D Reason: Covering the wound site with an occlusive dressing can help prevent air from entering the abdominal cavity and causing a pneumoperitoneum, which can impair breathing and circulation. This is an appropriate action for penetrating wounds, such as stab wounds.
Choice E Reason: Checking the client's distal pulses frequently can help monitor the perfusion of the extremities and detect signs of shock or compartment syndrome. Shock is a condition in which there is inadequate tissue perfusion due to blood loss or other causes. Compartment syndrome is a condition in which there is increased pressure within a muscle compartment due to swelling or bleeding, which can compromise blood flow and nerve function.