The nurse stops to assist an adolescent who has experienced severe trauma when hit by a motorcycle. The emergency medical system (EMS) has been activated. The first person who provided assistance applied a tourniquet to the child's leg
because of arterial bleeding. What should the nurse do related to the tourniquet?
a. Loosen the tourniquet.
b. Leave the tourniquet in place.
c. Remove the tourniquet and apply direct pressure if bleeding is still present.
d. Remove the tourniquet every 5 minutes, leaving it off for 30 seconds each time.
ANS: B
A tourniquet is applied only as a last resort, and then it is left in place and not loosened until definitive treatment is available. After the tourniquet is applied, skin and tissue necrosis occur below the site. Loosening or removing the tourniquet allows toxins from the tissue necrosis to be released into the circulation. This can induce systemic, deadly tourniquet shock.
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