A nurse working in an emergency department is caring for a client who has third-degree frostbite to both lower extremities. The nurse should take which of the following actions?

Massage the legs.

Apply dry heat to the legs.

Elevate the legs.

Immerse the legs in cold water.

Answer and Explanation

The Correct Answer is C

A. Massage the legs: This is incorrect. Massage is contraindicated as it can cause further tissue damage and is not appropriate for frostbite.
B. Apply dry heat to the legs: This is incorrect. Dry heat can exacerbate tissue damage. Rewarming should be done using controlled, warm water immersion, not dry heat.
C. Elevate the legs: This is correct. Elevating the legs helps reduce swelling and can prevent further tissue damage. However, rewarming should be done carefully in a controlled environment.
D. Immerse the legs in cold water: This is incorrect. Immersing in cold water would worsen the frostbite. Rewarming should be done using warm (not hot) water, ideally at 37-39°C (98.6-102.2°F), for effective treatment.

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Correct Answer is B

Explanation

A. Manually irrigate the catheter: This action is premature if the issue is due to a kink or obstruction in the tubing. Manual irrigation should only be performed if other less invasive measures do not resolve the issue.
B. Check the catheter tubing for kinks: This is the first step to take as kinks in the tubing can obstruct the flow of urine. Identifying and correcting kinks may resolve the problem without further intervention.
C. Notify the healthcare provider: This step may be necessary if other interventions do not resolve the issue, but it is not the first action.
D. Adjust the rate of the bladder irrigant: This may be relevant if the problem is related to the irrigation rate, but checking for kinks should be done first to ensure proper catheter function.

A. Allow a drinking glass on the client's meal tray. B. Place the client in four-point restraints. C. Inspect the client's personal belongings. D. Assign the client to a private room.

Correct Answer is C

Explanation

A. Allow a drinking glass on the client's meal tray: This is incorrect. Allowing objects that could potentially be used for self-harm is unsafe. All items on the client's meal tray should be carefully reviewed to ensure they do not pose a risk.
B. Place the client in four-point restraints: This is incorrect. Restraints are used as a last resort and should only be applied following a thorough assessment of the client's needs and risks, considering less restrictive measures first.
C. Inspect the client's personal belongings: This is correct. Inspecting personal belongings is crucial to ensure that the client does not have items that could be used for self-harm. This step helps in identifying and removing potential hazards.
D. Assign the client to a private room: This is incorrect. Assigning a client to a private room might not be appropriate as it could isolate the client and reduce opportunities for observation and intervention. A safer approach is to place the client in a room where they can be closely monitored, typically a shared room with staff supervision.

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A nurse working in an emergency department is caring for a client who has third-degree frostbite to both lower extremities. The nurse should take which of the following actions?

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