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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Bend at the knees to maintain a low center of gravity: Bending at the knees allows the nurse to use the strong muscles of the legs instead of the back, promoting proper body mechanics and reducing the risk of injury during lifting.

B. Ask the client to place hands on the nurse's shoulders: This is unsafe, as it may cause the client to pull the nurse off balance. Clients should be instructed to push off stable surfaces, such as the armrests of the wheelchair.

C. Stand with feet 3 inches (7.6 cm) apart for balance: A 3-inch stance does not provide adequate support. Feet should be about shoulder-width apart (usually 12–18 inches) to maintain a stable base during lifting or transferring.

D. Position self at the back of wheelchair with wheels locked: While locking the wheels is correct, standing behind the wheelchair does not assist the client in rising. The nurse should be in front or to the side to offer support during the transfer.

A. Determine pulse pressure. B. Check for neck vein distention. C. Auscultate heart sounds. D. Measure oxygen saturation

Correct Answer is D

Explanation

A. Determine pulse pressure: Pulse pressure may provide insight into cardiovascular status but does not directly address the immediate respiratory concern suggested by the use of accessory muscles.

B. Check for neck vein distention: Jugular vein distention could indicate cardiac dysfunction, but the priority should be to assess the client's oxygenation status when signs of respiratory effort are observed.

C. Auscultate heart sounds: While heart sounds may be part of a broader assessment, they do not provide immediate information about oxygenation or respiratory compromise.

D. Measure oxygen saturation: Accessory muscle use indicates increased work of breathing or possible respiratory distress. Measuring oxygen saturation is the most direct and immediate way to evaluate the client’s oxygenation status and guide urgent 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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Explanation

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Correct Answer is D

Explanation

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