A nurse is caring for a client who has a strained knee and a prescription for ice therapy. Which of the following actions should the nurse take?
Check the client's skin after 15 min.
Apply ice directly on the client's skin.
Tell the client ice therapy will increase blood flow.
Apply heat after 30 min of ice therapy.
The Correct Answer is A
Choice A reason: Checking the skin after 15 minutes is appropriate to prevent tissue injury such as frostbite. Ice therapy should be monitored closely to ensure safety and effectiveness.
Choice B reason: Applying ice directly to the skin is unsafe because it can cause frostbite and tissue damage. Ice should always be wrapped in a barrier such as a towel.
Choice C reason: Ice therapy decreases blood flow by causing vasoconstriction, which reduces swelling and inflammation. Saying it increases blood flow is incorrect.
Choice D reason: Heat therapy should not immediately follow ice therapy. Heat increases blood flow and swelling, which is contraindicated in the acute phase of injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Informing the provider is necessary, but it is not the first action. Before contacting the provider, the nurse must gather immediate data to assess the severity of the client’s condition. Without objective information, communication with the provider may be incomplete or delayed in urgency.
Choice B reason: Obtaining a pulse oximetry reading is the priority because the client is experiencing shortness of breath and chest pain, which may indicate impaired oxygenation. Pulse oximetry provides rapid, non-invasive data about oxygen saturation, guiding immediate interventions. This step ensures that the nurse can quickly determine if supplemental oxygen or emergency measures are required.
Choice C reason: Administering pain medication is important for comfort, but pain management is not the priority when the client shows signs of possible respiratory compromise. Addressing oxygenation and circulation must come before pain relief in acute trauma situations.
Choice D reason: Requesting a chest x-ray is appropriate for diagnostic purposes, but it is not the first action. Imaging takes time and requires physician orders. Immediate assessment of oxygenation is more urgent to stabilize the client before further diagnostics.
Correct Answer is A
Explanation
Choice A reason: Prolonged uterine contractions lasting 90 seconds indicate uterine tachysystole, a dangerous adverse effect of oxytocin. This can reduce placental perfusion, compromise fetal oxygenation, and increase risk of uterine rupture. Immediate intervention is required.
Choice B reason: Moderate variability of the fetal heart rate is a reassuring sign of adequate oxygenation and intact neurological function. It is not an adverse effect.
Choice C reason: Contractions every 2 minutes are within the normal therapeutic range for oxytocin augmentation. This frequency supports labor progression without compromising fetal well-being.
Choice D reason: A fetal heart rate of 150/min is within the normal baseline range (110–160/min). This is not an adverse effect.
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