The patient started bleeding profusely from a surgical wound on the thigh. Nursing care is appropriate if the nurse takes which action to care for this patient?
a. Assesses the wound for sinus tracts and tunneling
b. Applies roller gauze over the gauze pads on the extremity using a figure-eight pat-tern
c. Obtains sterile gauze and sterile gloves
d. Has nursing assistive personnel (NAP) apply the pressure dressing
B
Assessing the wound for sinus tracts and tunneling would increase the hemorrahging. Since this is a fresh wound there is no need to do this. The figure-eight pattern of wrapping acts as a pres-sure dressing, exerting even pressure over the extremity. Assessment has indicated that the pa-tient is hemorrhaging. Pressure needs to be applied to the area to prevent blood loss and patient deterioration. Sterile technique is not the priority at this time. As long as the dressings are clean, they can be applied. The nurse needs only clean gloves. The skill of applying a pressure bandage in an emergent situation should not be delegated to the NAP. If the application requires more than one person, the NAP can assist the nurse as directed.
You might also like to view...
Which infant should be seen immediately by a pediatrician?
a. A 2-week-old infant with nasal congestion and respirations of 64 breaths per minute b. A 1-week-old infant with a diaper rash c. A 1-month-old infant with an axillary temperature of 99.8° F d. A 3-week-old breast-fed infant who has had two loose stools
With which client should the nurse be alert to the possibility of latex hypersensitivity?
A. 38-year-old man allergic to shellfish B. 28-year-old woman with spina bifida C. 68-year-old man with total hip replacement D. 38-year-old woman taking oral contraceptives
The clinical instructor interprets the development of mutual goals and guidelines as
a. norming. c. storming. b. performing. d. informing.
A patient has been placed in an anger management group because he has trouble controlling his angry outbursts. The nurse interprets this type group as an example of which of the following?
A) Psychotherapy B) Self-help C) Psychoeducation D) Supportive therapy