A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling?

Injection of a steroid into the joint space

Elevation of the extremity

Warm compresses

Ice bag

Answer and Explanation

The Correct Answer is D

A. Injection of a steroid into the joint space: Steroid injections reduce inflammation but are typically reserved for chronic conditions or severe joint inflammation. They are not an immediate first-line treatment for acute injuries like ankle sprains.
B. Elevation of the extremity: Elevation helps reduce swelling by promoting venous return, but it does not directly cause vasoconstriction. While beneficial, it works best in combination with cold therapy to reduce acute inflammation.
C. Warm compresses: Applying heat increases blood flow through vasodilation, which can worsen swelling in an acute injury. Warm compresses are more appropriate for chronic pain or stiffness, not fresh trauma.
D. Ice bag: Cold therapy causes local vasoconstriction, which helps limit bleeding and fluid accumulation. Applying an ice bag within the first 24–48 hours after injury effectively reduces swelling and pain by slowing the inflammatory process.

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Correct Answer is B

Explanation

A. Eating alone so the client can eat at his own pace and not be hurried: While avoiding pressure during meals can help, eating alone may contribute to social isolation and decrease interest in food. Mealtime companionship often encourages intake and comfort.
B. Preparing cool or cold foods that may be better tolerated: Cool or cold foods often have less odor and are easier to tolerate, especially for clients with nausea or decreased appetite. This can reduce sensory overload and make eating more pleasant.
C. Providing several choices on the plate so that the client has what may appeal to him: Too many options at once can be overwhelming and reduce appetite in some clients. Simpler, smaller servings may be more effective than offering multiple foods at once.
D. Offering high caloric foods to build fat and muscle: While calorie-dense foods are useful, the primary goal in end-of-life care is comfort and appetite stimulation, not rebuilding muscle. Forcing high-calorie intake can lead to resistance or nausea.

A. Administer the medications and then notify the health care provider. B. Administer atropine to speed the heart rate and then administer the digoxin. C. Administer the medication and inform the charge nurse about the rate. D. Withhold the medication and notify the health care provider of the heart rate.

Correct Answer is D

Explanation

A. Administer the medications and then notify the health care provider: Administering digoxin with a heart rate below 60 bpm can worsen bradycardia and lead to complications like heart block. The drug should be withheld first.
B. Administer atropine to speed the heart rate and then administer the digoxin: Atropine is not given prophylactically without a provider's order. It is used in emergency settings for symptomatic bradycardia, not as a pre-treatment for digoxin.
C. Administer the medication and inform the charge nurse about the rate: This does not follow safe medication guidelines. Administering digoxin without addressing the low heart rate may lead to serious adverse effects.
D. Withhold the medication and notify the health care provider of the heart rate: This is the safest and most appropriate action. Digoxin should be withheld if the apical pulse is below 60 bpm, and the provider must be informed for further evaluation.

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A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The family of a client who is dying and being cared for at home is requesting information on how best to prepare food. Which suggestion by the nurse may stimulate appetite?

Correct Answer is B

Explanation

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

Correct Answer is D

Explanation

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