A client presents the emergency department with a Grade II ankle sprain. Which of the following interventions should the nurse implement?

Encourage the client to walk on the injured ankle to promote circulation.

Immerse the ankle in want water immediately after the in

Apply ice to the affected ankle for the first 24-72 hours.

Perform deep tissue massage on the injured area to reduce pain.

Answer and Explanation

The Correct Answer is C

A. Encourage the client to walk on the injured ankle to promote circulation. Weight-bearing activities should be avoided initially after a Grade II sprain to prevent further injury.

B. Immerse the ankle in warm water immediately after the injury. Ice, rather than warmth, is recommended immediately following an injury to reduce swelling and inflammation.

C. Apply ice to the affected ankle for the first 24-72 hours. Applying ice for 24-72 hours helps reduce swelling and pain by causing vasoconstriction and controlling inflammation in the acute phase.

D. Perform deep tissue massage on the injured area to reduce pain. Massaging a newly sprained ankle can aggravate inflammation and cause additional tissue damage.

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Correct Answer is D

Explanation

A. Include high-fat foods to maintain weight. High-fat foods can worsen symptoms in ulcerative colitis by increasing bowel irritation and causing malabsorption. A balanced diet that is low in fat is usually recommended.

B. Eat three large meals a day to ensure adequate nutrition. Large meals can increase digestive workload and exacerbate symptoms. Smaller, more frequent meals are generally better tolerated.

C. Increase intake of dairy products to boost calcium levels. Many patients with ulcerative colitis are lactose intolerant or sensitive to dairy, which can worsen symptoms. Calcium can be obtained from other sources if needed.

D. Consume a low-fiber diet to minimize bowel irritation. A low-fiber diet can reduce mechanical irritation in the bowel, which is beneficial during flare-ups of ulcerative colitis.

A. Keep the patient NPC (nothing by mouth) until the T-tube is removed. B. Monitor the tube drainage and document the amount and color. C. Ensure the tube is clamped for 8 hours each day. D. Flush the T-tube with normal saline every 4 hours.

Correct Answer is B

Explanation

A. Keep the patient NPO (nothing by mouth) until the T-tube is removed. Patients are generally kept NPO initially but may resume clear liquids and progress to a regular diet based on tolerance; NPO status is not required until the T-tube is removed.

B. Monitor the tube drainage and document the amount and color. Monitoring and documenting drainage from the T-tube is crucial to assess biliary function and ensure that the bile is draining properly, indicating no obstruction.

C. Ensure the tube is clamped for 8 hours each day. Clamping may be done before tube removal to test the body’s tolerance to bile drainage, but it should be done only as per physician orders, not routinely for 8 hours each day.

D. Flush the T-tube with normal saline every 4 hours. Flushing a T-tube is generally not done routinely as it could disrupt the flow of bile and cause complications.

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A client presents the emergency department with a Grade II ankle sprain. Which of the following interventions should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing dietary teaching to a patient with ulcerative colitis. Which of the following instructions should the nurse include?

Correct Answer is D

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