The newly hired nurse cares 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 by the charge nurse?
The newly hired nurse cares 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 by the charge nurse?
A. Applying a tourniquet proximal to the bite.
[55%]
B. Removing the client’s wristwatch and jewelry.
[7%]
C. Establishing intravenous (IV) access.
[5%]
D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
[33%]
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Environmental Emergencies
Client Need
Test Plan
Physiological Adaptation
Related Topic
Medical Emergencies
Item Type
Item Type
Application
Explanation
Choice A is correct. Tourniquets should not be used in snake bites. The tourniquet impedes arterial blood flow and can be quite harmful to the extremity. The client should immobilize the affected extremity to decrease the absorption of the venom.
Choices B, C, and D are incorrect.
- It would be appropriate to remove the jewelry and the wristwatch as these may impede the blood flow once the affected extremity swells (choice B).
- Establishing intravenous (IV) access and collecting laboratory tests such as PTT, PT/INR, platelets, and CPK are necessary (choice C). Snake venom may cause disseminated intravascular coagulation (DIC) and life-threatening bleeding; thus, obtaining this laboratory work is critical. PT and PTT are prolonged in DIC. An elevated CPK indicates rhabdomyolysis.
- If complications such as DIC arise, blood products are essential. Therefore, obtaining the type and crossmatch is necessary (choice D). A common blood product used to treat coagulopathy caused by snake venom is fresh frozen plasma (FFP).
Additional Info
✓ 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 local poison control will determine antivenom treatment.
✓ The nurse should obtain vital signs, initiate intravenous (IV) therapy, collect laboratory work, and monitor for complications such as bleeding, neurovascular compromise, disseminated intravascular coagulation, rhabdomyolysis, shock, and renal failure.
✓ The nurse should also contact poison control for guidance on the client's care.
