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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["56"]
Explanation
To calculate the infusion rate, we'll use the following formula:
Infusion rate (gtt/min) = (Volume to be infused (mL) / Time (min)) Drop factor (gtt/mL)
First, calculate the total time in minutes:
- 3 hours 60 minutes/hour = 180 minutes
Then, calculate the volume per minute:
- 500 mL / 180 minutes = 2.78 mL/min
Finally, multiply the volume per minute by the drop factor:
- 2.78 mL/min 20 gtt/mL = 55.6 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 56 gtt/min.
Correct Answer is C
Explanation
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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