A client requests heat therapy for lower back pain. Which action should the nurse take?

Obtain a prescription for heat application.

Use moist towel as a skin barrier.

Assess skin every 30 minutes after application.

Demonstrate use of temperature control.

Answer and Explanation

The Correct Answer is A

A. Obtain a prescription for heat application: Heat therapy is considered a therapeutic intervention that can impact circulation, tissue integrity, and sensation. Therefore, the nurse should first obtain a provider’s order before applying it to ensure safety and appropriateness based on the client’s condition.

B. Use moist towel as a skin barrier: A moist towel may enhance heat penetration and reduce the risk of burns, but it is not the priority action before confirming whether heat therapy is permitted for the client through a medical order.

C. Assess skin every 30 minutes after application: Monitoring the skin is necessary once heat is applied, but assessment occurs after the therapy begins. It does not precede the essential step of getting authorization to initiate treatment.

D. Demonstrate use of temperature control: Teaching the client to adjust temperature settings is useful when self-administering therapy, but it comes after verifying the appropriateness and safety of the intervention through a healthcare provider’s prescription.

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Correct Answer is A

Explanation

A. Consult the posted mobility algorithm for client transfers: Mobility algorithms provide structured guidance to safely assist clients with varying degrees of mobility. Referring to these algorithms ensures that transfers are done safely using appropriate equipment or assistance based on the client’s needs.

B. Keep the feet together and bend at the waist when lifting: This action increases the risk of back injury due to poor body mechanics. Proper lifting technique involves bending at the knees and keeping feet shoulder-width apart for better stability and spinal alignment.

C. Use a pulling motion when transferring and moving a client: Pulling can strain the back and shoulders of the caregiver and may cause harm to the client. A pushing motion is safer and allows better control during movement or repositioning.

D. Avoid lifting more than 45 pounds (18 kg) independently: While avoiding heavy lifting is important, the standard maximum safe lifting weight varies and should be guided by facility policy and ergonomic recommendations.

A. Provide a numeric pain scale. B. Observe body language and movement C. Identify effective pain relief measures. D. Ask the client to describe the pain.

Correct Answer is D

Explanation

A. Provide a numeric pain scale: A numeric scale helps assess the intensity of pain, not its quality. It informs how severe the pain feels but does not give insight into the type or nature of the discomfort.

B. Observe body language and movement: Nonverbal cues help identify the presence of pain, especially in nonverbal clients, but they are not specific enough to describe the quality or characteristics of the pain.

C. Identify effective pain relief measures: Understanding what relieves pain is part of pain management but does not directly assess the quality or nature of the pain being experienced.

D. Ask the client to describe the pain: This allows the nurse to gather specific details about the pain's quality—such as whether it is sharp, burning, throbbing, or dull—which is essential for diagnosis and targeted interventions.

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A client requests heat therapy for lower back pain. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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