A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

2+ pitting edema

7.5 cm (3 in) diameter bruise on the ankle

Capillary refill 4 seconds

Warts on the affected ankle

Answer and Explanation

The Correct Answer is C

A.   2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B.   A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C.   Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D.   Warts on the affected ankle are not a contraindication to cold application.

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Correct Answer is B

Explanation

A. Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B. Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.

C. Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D. Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.

A. Wrapping the finger in a warm cloth B. Rubbing the fingertip with an alcohol pad C. Puncturing the side of the fingertip D. Elevating the finger above heart level

Correct Answer is D

Explanation

A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.

C. Puncturing the side of the fingertip is less painful and avoids the pain receptors.

D. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.

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A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Correct Answer is B

Explanation

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Correct Answer is D

Explanation

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