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 ["A","C","E"]
Explanation
Choice A rationale:
Elevate the affected limb.
Elevating the affected limb is an appropriate nursing intervention for managing cellulitis.
It helps reduce swelling and promotes better circulation, which can aid in the healing process.
Choice B rationale:
Apply cold compresses to the area.
This is not an appropriate nursing intervention for cellulitis.
Cold compresses may provide relief for some types of skin conditions but are not recommended for cellulitis, as they can potentially worsen the condition.
Choice C rationale:
Administer antibiotics as prescribed.
Administering antibiotics is a crucial nursing intervention for managing cellulitis.
Cellulitis is typically treated with antibiotics to eliminate the underlying bacterial infection.
Choice D rationale:
Encourage the client to scratch the affected area.
This is not an appropriate nursing intervention.
Scratching can introduce more bacteria into the affected area, potentially worsening the infection.
Choice E rationale:
Provide education on proper wound care.
Educating the client on proper wound care is essential for managing cellulitis.
Teaching the client to keep the wound clean, dry, and covered can help prevent further infection and promote healing.
Correct Answer is D
Explanation
Choice A rationale:
Poor hygiene.
Poor hygiene is a known risk factor for cellulitis.
Inadequate hygiene practices can lead to an increased risk of skin infections, including cellulitis.
Choice B rationale:
Diabetes.
Diabetes is a known risk factor for cellulitis.
People with diabetes are more susceptible to skin infections due to impaired immune function and poor circulation.
Choice C rationale:
Recent surgery or invasive procedures.
Recent surgery or invasive procedures are known risk factors for cellulitis.
These procedures can disrupt the skin's protective barrier, making it easier for bacteria to enter and cause infection.
Choice D rationale:
Allergic reaction to antibiotics.
This is not a known risk factor for cellulitis.
While allergies to antibiotics can cause various reactions, including skin rashes, they are not considered a direct risk factor for cellulitis.
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