A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?
Having the client perform range-of-motion exercises of the arm
Inspecting the site for reduced swelling
Asking the client to rate the pain
Monitoring the client's pulse rate
The Correct Answer is C
The correct answer is c. Asking the client to rate the pain. This is the most direct and reliable method to determine the effectiveness of a cold compress for pain relief.
Choice A Reason:
Having the client perform range-of-motion exercises of the arm: This statement is incorrect because it assesses mobility rather than pain or swelling. Range-of-motion exercises are typically used to evaluate joint flexibility and muscle strength, not the effectiveness of pain relief measures.
Choice B Reason:
Inspecting the site for reduced swelling: This statement is incorrect because, while it checks for swelling, it does not directly measure pain relief. Swelling reduction can be an indicator of decreased inflammation, but it does not provide a direct assessment of the client's pain levels.
Choice C Reason:
Asking the client to rate the pain: This is the correct choice because it directly measures the client's perception of pain. Pain is a subjective experience, and the most accurate way to assess it is by asking the client to describe or rate their pain. This method allows the nurse to gauge the effectiveness of the cold compress in providing pain relief.
Choice D Reason:
Monitoring the client's pulse rate: This statement is incorrect because pulse rate is not a direct indicator of pain or swelling reduction. While pain can sometimes cause an increase in pulse rate, it is not a reliable or specific measure of pain relief. Pulse rate can be influenced by various factors, including stress, anxiety, and physical activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Airborne precautions are used for diseases that are spread through the air over long distances, such as tuberculosis, measles, or chickenpox. VRE is not typically spread through the air.
Choice B reason: Droplet precautions are used for diseases that are spread through large droplets in the air, such as influenza or pertussis. VRE is not spread through droplets but through contact with contaminated surfaces or equipment.
Choice C reason: A protective environment is designed to protect immunocompromised patients from infection and is not typically used for patients with VRE. This type of precaution includes the use of HEPA filters, laminar air flow, and other strategies to maintain a sterile environment.
Choice D reason: Contact precautions are the appropriate measures for a patient with a VRE infection. VRE can be spread from one person to another through contact with contaminated surfaces or equipment or through person-to-person spread, often via contaminated hands. It is not spread through the air by coughing or sneezing. Therefore, contact precautions, including the use of gloves and gowns, are necessary when caring for patients with VRE to prevent the spread of the bacteria.
Correct Answer is B
Explanation
Choice A reason: Scarlet fever is caused by a bacterium that produces a toxin leading to a rash. It is typically spread through respiratory droplets, and while standard precautions are necessary, an N95 respirator is not required.
Choice B reason: Tuberculosis is an airborne infectious disease that requires the use of an N95 respirator to protect against inhaling the bacteria, especially in cases of pulmonary tuberculosis. This type of respirator filters out at least 95% of airborne particles, including Mycobacterium tuberculosis.
Choice C reason: Mycoplasmal pneumonia, also known as "walking pneumonia," is caused by Mycoplasma pneumoniae and is typically less severe than other types of bacterial pneumonia. Standard precautions, including the use of surgical masks, may be sufficient unless there is a risk of aerosol-generating procedures.
Choice D reason: Scabies is caused by a mite that burrows into the skin. It is spread through direct skin-to-skin contact, and an N95 respirator is not needed for protection against scabies.
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