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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Gloves are typically removed first because they are likely to be the most contaminated. They should be removed carefully to avoid contaminating the hands, using the glove-in-glove or beak method.

Choice B reason: The gown should be removed after the gloves because it may also be contaminated. The nurse should reach up to the shoulders and carefully pull the gown forward and away from the body, touching only the inside of the gown.

Choice C reason: Eyewear is removed after the gown. The nurse should handle the eyewear by the arms, avoiding touching the front part that has been exposed to contaminants.

Choice D reason: The mask should be removed last because it protects the mucous membranes of the mouth and nose from infectious droplets. It should be taken off by handling the ties or elastic bands from behind the head and pulling it away from the face without touching the front of the mask.

A. Systemic B. Health care-associated C. Endogenous D. Exogenous

Correct Answer is B

Explanation

Choice A reason: A systemic infection would affect the entire body or multiple systems, not just the urinary tract. While a urinary tract infection can become systemic if it leads to sepsis, the scenario provided does not specify such progression.

Choice B reason: A health care-associated infection (HAI) is an infection that a patient acquires while receiving treatment for another condition within a healthcare setting. Since the infection occurred after the insertion of a urinary catheter in a hospital, it is considered an HAI.

Choice C reason: An endogenous infection originates from the host's own microbial flora. The scenario does not provide enough information to determine if the infection was caused by the client's own flora or by external sources.

Choice D reason: An exogenous infection comes from outside the body. While the urinary tract infection could be exogenous, the scenario suggests it is more likely to be health care-associated due to the timing and context of the catheter insertion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

Correct Answer is D

Explanation

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

Correct Answer is B

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