A nurse is assessing a patient with localized redness, warmth, and swelling in the lower limb. The patient reports pain and tenderness at the affected site.
Which nursing intervention is appropriate for this patient?
Administering anticoagulant medication.
Applying cold compresses to the affected area.
Encouraging the patient to ambulate frequently.
Administering acetaminophen for pain relief.
The Correct Answer is B
Choice A rationale:
Administering anticoagulant medication is not appropriate for a patient with localized redness, warmth, swelling, pain, and tenderness in the lower limb.
These symptoms suggest a potential inflammatory or infectious process, not a blood clot.
Anticoagulants are used to prevent or treat blood clots, and there is no indication for their use based on the presented symptoms.
Choice B rationale:
Applying cold compresses to the affected area is an appropriate nursing intervention for a patient with localized redness, warmth, swelling, pain, and tenderness.
These symptoms are indicative of inflammation or infection, and cold compresses can help reduce inflammation, relieve pain, and provide comfort to the patient.
Choice C rationale:
Encouraging the patient to ambulate frequently may not be appropriate at this stage.
Ambulation is generally encouraged to prevent complications such as deep vein thrombosis (DVT) in hospitalized patients.
However, in the presence of localized redness, warmth, swelling, pain, and tenderness, it is essential to identify the underlying cause and provide appropriate treatment and rest before promoting ambulation.
Choice D rationale:
Administering acetaminophen for pain relief is a reasonable option, but it addresses only the symptom (pain) and not the underlying cause of the patient's condition.
While pain management is important for patient comfort, it should be combined with interventions that directly address the inflammation or infection responsible for the symptoms.
Therefore, choice B (cold compresses) is a more appropriate initial intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Reduced pain and swelling are not typically associated with abscess formation in cellulitis.
Abscesses are often characterized by localized pain, swelling, and the presence of pus.
The development of an abscess can indicate a more severe infection.
Choice B rationale:
Spreading of the infection to deeper tissues or the bloodstream (sepsis) is a potential complication associated with cellulitis when abscess formation occurs.
If an abscess forms, bacteria can enter the bloodstream, leading to sepsis, a life-threatening condition.
Early recognition and treatment are essential to prevent sepsis.
Choice C rationale:
Improved wound healing is not a typical outcome when cellulitis leads to abscess formation.
Abscesses can impede wound healing and may require drainage and antibiotic treatment to resolve.
Choice D rationale:
Decreased redness and warmth at the site are not expected outcomes when an abscess forms in cellulitis.
Abscesses are often associated with increased redness and warmth due to inflammation and infection.
Correct Answer is B
Explanation
Choice A rationale:
Maintaining good hand hygiene is essential in preventing cellulitis and other infections.
Discouraging hand hygiene is not appropriate advice.
Proper handwashing can help reduce the risk of infection transmission.
Choice B rationale:
The nurse should advise the patient to promptly treat any cuts, wounds, or insect bites to prevent cellulitis.
This is a valid and important preventive measure.
Prompt wound care, including cleaning, disinfection, and covering wounds, can reduce the risk of infection.
Choice C rationale:
Sharing personal items with others is not a safe practice in preventing cellulitis.
Sharing items like towels, razors, or personal care items can increase the risk of bacterial transmission and infection.
The nurse should advise against sharing personal items.
Choice D rationale:
Avoiding a healthy lifestyle can impact an individual's overall health, including their immune system function, which can influence their risk of cellulitis.
However, it's not the primary focus of preventive measures for cellulitis.
The nurse should encourage a healthy lifestyle but also provide specific advice on wound care and hygiene to prevent cellulitis.
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