A patient presents with a bluish discoloration on the skin following a fall. Which nursing intervention is most appropriate to assess the severity of the contusion?
Instruct the patient to avoid using the injured limb.
Assess for pain and swelling at the injury site.
Administer analgesics without further assessment.
Apply a warm compress to the area immediately.
The Correct Answer is B
A. Instruct the patient to avoid using the injured limb: This is part of the treatment (Rest) but is an intervention, not the most appropriate immediate step for assessing the severity of the injury.
B. Assess for pain and swelling at the injury site: A contusion involves damaged capillaries, leading to bleeding into the tissues, which causes the bluish discoloration, swelling, and pain. The most appropriate immediate nursing assessment involves checking for the extent of swelling, which can indicate underlying hematoma formation, and the level of pain, which guides the need for further diagnostics (like an X-ray to rule out fracture) or pain management.
C. Administer analgesics without further assessment: Pain is a crucial indicator of injury severity. Administering medication before a proper assessment can mask symptoms of a more serious, underlying injury (like a fracture or compartment syndrome).
D. Apply a warm compress to the area immediately: For acute contusions, cold therapy (ice) is used initially to cause vasoconstriction, which helps limit bleeding, decrease swelling, and reduce pain. A warm compress would promote vasodilation, potentially increasing the bleeding and swelling.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Presence of slough or eschar: Both Stage 2 and Stage 3 injuries may eventually develop some slough if they deteriorate or if they are mismanaged. However, slough and eschar are defining characteristics of an unstageable injury if they obscure the wound base. A clean Stage 2 injury will not have slough or eschar.
B. Nonblanchable erythema: Nonblanchable erythema is the defining characteristic of a Stage 1 pressure injury, which involves intact skin. Stage 2 and Stage 3 both involve skin loss.
C. Exposed muscle or bone: Exposed muscle or bone indicates a Stage 4 pressure injury.
D. Partial-thickness skin loss: A Stage 2 pressure injury is defined by partial-thickness loss of the dermis. A Stage 3 pressure injury is defined by full-thickness tissue loss involving the subcutaneous fat. This difference in thickness is the key distinction.
Correct Answer is C
Explanation
A. Educating the patient about completing the full course of antibiotics: This is a crucial education point for all antibiotics to prevent resistance but is not the most critical specific nursing action to ensure the effectiveness of vancomycin therapy.
B. Obtaining cultures and sensitivities before starting the antibiotic: This is a necessary step in the initial management of infection to confirm the pathogen and guide therapy, but since the question states the infection is "confirmed MRSA" and the patient "is being treated with vancomycin," this step has likely already occurred.
C. Administering the medication at the exact scheduled time:Vancomycin requires precise dosing intervals to maintain the necessary therapeutic drug level (Trough) in the blood, making timely administration important. However, monitoring is key.
D. Monitoring the patient's renal function: This is the most critical nursing action. Vancomycin is nephrotoxic (toxic to the kidneys). To ensure the effectiveness of treatment while preventing toxicity, the nurse must monitor the patient's BUN and Creatinine (renal function) and ensure that peak and trough drug levels are drawn as ordered. The trough level (the lowest level) is especially critical as it confirms the dose is effective without being toxic.
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