A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
a. Inspect the wound for foreign bodies.
b. Inspect the wound for bleeding.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.
ANS: B
After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.
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