A client requests heat therapy for lower back pain. Which action should the nurse take?
Demonstrate use of temperature control.
Use moist towel as a skin barrier.
Assess skin every 30 minutes after application.
Obtain a prescription for heat application.
The Correct Answer is D
Choice A reason: Demonstrating temperature control is relevant but secondary to obtaining a prescription. Heat therapy increases blood flow, relaxing muscles, but requires medical approval to ensure safety, as improper use risks burns or exacerbates conditions like inflammation. A prescription confirms appropriateness, making this action premature without authorization.
Choice B reason: Using a moist towel as a barrier enhances heat conduction but is not the first step. Heat therapy requires a prescription to verify its suitability, as it may worsen conditions like acute inflammation. Without medical approval, applying heat risks harm, making this action inappropriate before confirming the order.
Choice C reason: Assessing skin every 30 minutes monitors for burns but follows prescription and application. Heat therapy vasodilates vessels, relieving pain, but requires a physician’s order to ensure it’s indicated. Starting therapy without authorization risks adverse effects, like tissue damage, making skin assessment secondary to obtaining a prescription.
Choice D reason: Obtaining a prescription is the first action, as heat therapy requires medical approval to ensure it’s safe and indicated for lower back pain. Heat increases blood flow, but conditions like malignancy or acute injury contraindicate it. A prescription ensures appropriate use, preventing harm, making this the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Demonstrating medication administration teaches, not evaluates understanding. Inquiring about frequency confirms the client’s knowledge of the regimen, ensuring adherence. Demonstration is an instructional method, not an assessment tool, per patient education and medication safety standards in nursing practice.
Choice B reason: Asking for additional questions identifies gaps but does not directly assess understanding of the regimen. Inquiring about frequency evaluates specific knowledge critical for adherence. Questions are supplementary, per patient education and comprehension assessment principles in medication teaching protocols.
Choice C reason: Recognizing confusion is part of teaching but not a direct evaluation of understanding. Inquiring about frequency tests retention of key information, ensuring safe administration. Confusion assessment is indirect, per medication education and patient comprehension standards in nursing care.
Choice D reason: Inquiring about frequency of administration directly evaluates the client’s understanding of the prescription, confirming knowledge of dosing intervals critical for adherence and safety. This targeted question assesses retention, guiding further teaching if needed, per patient education and medication safety protocols in nursing practice.
Correct Answer is C
Explanation
Choice A reason: Using movement techniques taught by physical therapists indicates correct understanding, as it promotes safe mobility and recovery. No additional instruction is needed, as this aligns with postoperative care plans, ensuring the client follows evidence-based rehabilitation strategies to prevent complications, per discharge teaching and physical therapy guidelines.
Choice B reason: Notifying the healthcare provider about a fever shows appropriate understanding, as it indicates awareness of infection risks post-surgery. This requires no further instruction, as it aligns with standard discharge education on monitoring for complications, ensuring timely intervention, per postoperative care and patient safety protocols.
Choice C reason: Calling the pharmacy to determine medications indicates a knowledge gap, as the client should receive clear instructions from the healthcare team. This requires additional instruction to ensure accurate medication adherence, preventing errors or complications, per discharge planning and medication reconciliation standards in postoperative care.
Choice D reason: Verifying a follow-up appointment demonstrates correct understanding, as it ensures continuity of care. No additional instruction is needed, as this aligns with discharge planning, promoting monitoring of recovery and timely intervention for complications, per patient education and healthcare coordination guidelines in surgical care.
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