A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad. Which of the following actions should the nurse take?

Apply the pad for 45 min per application.

Cover the pad with a pillowcase before application.

Set the temperature of the aquathermia pad to 50° C (122° F).

Use safety pins to hold the pad in place.

Answer and Explanation

The Correct Answer is B

A. Apply the pad for 45 min per application: Heat therapy should generally be limited to 20 to 30 minutes to avoid burns and rebound vasoconstriction. Applying for 45 minutes increases the risk of tissue injury and is not recommended.

B. Cover the pad with a pillowcase before application: Placing a thin barrier, such as a pillowcase, between the aquathermia pad and the skin helps prevent direct contact and reduces the risk of burns. This is the safest and most appropriate action.

C. Set the temperature of the aquathermia pad to 50° C (122° F): The typical safe range for aquathermia pads is around 40° C (104° F). Setting the temperature to 50° C poses a high risk of skin injury, especially in clients with impaired sensation or circulation.

D. Use safety pins to hold the pad in place: Safety pins can puncture the tubing of the pad, leading to leaks and malfunction. Straps or covers designed for the device should be used instead to secure it safely.

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Correct Answer is D

Explanation

A. Assist the client in making decisions about the need for life support: Nurses can provide education about treatment options, but making decisions about life support is the client’s responsibility, often in consultation with their provider.

B. Notify the provider of the client's durable power of attorney for health care: While important in care planning, notifying the provider is not the nurse’s primary responsibility under the PSDA. The act requires that clients be asked about advance directives and informed of their rights first.

C. Clarify the legal competency of the client: Determining legal competency is a responsibility of the courts, not nurses. Nurses assess decision-making capacity, but under the PSDA, the main role is to ask and provide information about advance directives.

D. Ask the client whether they have created advance directives: The PSDA requires healthcare institutions to inform clients of their right to make decisions regarding their care, including the right to have advance directives. Asking about existing directives fulfills the nurse’s obligation under this law.

A. Use a reflex hammer. B. Administer magnesium sulfate. C. Perform a Romberg test. D. Test the gait for symmetry.

Correct Answer is A

Explanation

A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.

B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.

C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.

D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.

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A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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