Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage
The client is otherwise stable. What action should the nurse take?
1. Place a tourniquet above the wound.
2. Remove the dressing and place direct pressure on the wound.
3. Add an additional dressing to the wound without removing the original.
4. Remove the dressing and replace it with a new sterile dressing.
Correct Answer: 3
Rationale 1: A tourniquet should not be applied because of the risk of interrupting arterial flow to the tissues.
Rationale 2: Removing the dressing and applying direct pressure would take too much time at this point.
Rationale 3: In this scenario, where there are multiple clients in need of care and because this client is stable, the correct nursing action is to add an additional dressing to the wound without removing the original.
Rationale 4: Removing the dressing and replacing the dressing with a new sterile dressing would take too much time at this point.
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