Nclex-pn Readiness Test 1
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Nclex-pn Readiness Test 1
The nurse is working with a new nurse who is caring for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up?
Choice A is correct. Applying a tourniquet proximal to the snake bite is not recommended in the case of venomous snake bites. It can lead to further complications by concentrating the venom in one area and may cause tissue damage. Current guidelines recommend against using tourniquets for snake bites. The priority is to immobilize the affected extremity and keep it below the level of the heart to slow down the spread of venom.
Choice B is incorrect. Removing the client's wristwatch and jewelry is a necessary intervention. It ensures that there is no constriction on the affected limb, which could impede circulation. This action allows for proper assessment and monitoring of the affected area for signs of swelling or worsening symptoms.
Choice C is incorrect. Immobilizing the affected extremity is a crucial intervention for snake bites. Keeping the limb still and below the level of the heart helps slow down the spread of venom through the lymphatic system. Immobilization prevents further movement of the affected area, reducing the risk of venom circulation and minimizing the impact on vital organs.
Choice D is incorrect. Obtaining a type and crossmatch for fresh frozen plasma is not an immediate priority in the management of a venomous snake bite. The primary focus should be on immobilization, keeping the affected limb below the heart level, and seeking medical assistance for antivenom administration. Antivenom is the specific treatment for snake bites and should be administered promptly to counteract the effects of the venom.
✓ Venomous snake bites can be fatal if emergency treatment is not promptly obtained.
✓ The client should immobilize the affected extremity, remove any jewelry, and seek emergent care.
✓ The nurse should obtain vital signs, initiate intravenous (IV) therapy, collect laboratory work, and monitor bleeding, neurovascular compromise, shock, and renal failure.
✓ The nurse should also contact poison control for guidance on the client's care. The local poison control will determine antivenom treatment.