The client has an open wound on the right ankle that the registered nurse has cleansed and dressed with gauze. The nurse now needs to apply a conforming ace bandage to keep the dressing in place.
What technique will the nurse use to apply the bandage on the ankle?
Circular turns only
Figure-of-eight turns only
Spiral turns only
Recurrent bandaging only
The Correct Answer is C
Choice A rationale:
Circular turns involve wrapping the bandage around the limb in a continuous circle, with each layer overlapping the previous one. While this technique is effective for securing dressings on cylindrical body parts like the arm or thigh, it's not ideal for joints like the ankle. Circular turns can constrict movement and potentially impair circulation, especially if applied too tightly. Additionally, they don't provide adequate compression for wounds that require it.
Choice B rationale:
Figure-of-eight turns create a cross-over pattern around the joint, resembling the number 8. This technique offers better flexibility and movement compared to circular turns, but it's still not the most appropriate for the ankle. The cross-over pattern can create uneven pressure points and potentially lead to discomfort or even skin irritation. Moreover, it might not provide sufficient compression for wound management.
Choice C rationale:
Spiral turns involve wrapping the bandage diagonally, ascending or descending the limb, with each layer overlapping the previous one by about half its width. This technique is considered the most suitable for bandaging joints like the ankle for several reasons:
Conforms to Joint Contours: Spiral turns naturally mold to the shape of the ankle, providing even pressure distribution and avoiding constriction points. This ensures comfort and maintains proper blood flow.
Allows for Movement: The diagonal pattern accommodates the natural flexion and extension of the ankle joint, allowing for greater mobility without compromising bandage integrity.
Provides Effective Compression: Spiral turns can be applied with varying degrees of compression to suit the needs of the wound and surrounding tissue. This can help control bleeding, reduce swelling, and promote healing.
Easy to Apply and Adjust: Spiral turns are relatively straightforward to apply and can be easily adjusted if needed, making them adaptable to different wound sizes and patient needs.
Choice D rationale:
Recurrent bandaging involves wrapping the bandage back and forth over the same area multiple times, creating a thicker layer. This technique is primarily used for stumps or areas requiring significant padding and absorption. It's not typically used for bandaging joints like the ankle, as it can create excessive bulk and potentially restrict movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While it's true that gastrointestinal peristalsis may be slowed after surgery, this is not the primary reason for administering a cleansing enema before colon surgery.
The main goal of the enema is to evacuate stool from the colon, ensuring a clear and unobstructed surgical field. This helps to:
Reduce the risk of infection
Facilitate better visualization of the colon during surgery
Minimize the potential for complications
Choice B rationale:
Cleansing enemas are not administered solely based on patient request.
They are prescribed for specific medical reasons, such as preparing for colon surgery or certain diagnostic procedures. Patient preference may be considered, but it's not the determining factor.
Choice C rationale:
While decreased gas and discomfort post-operatively can be a potential benefit of a cleansing enema, it's not the primary reason for its use before colon surgery.
The primary goal, as mentioned earlier, is to clear the colon for a safe and effective surgical procedure. However, reduced gas and discomfort can contribute to a smoother post-operative recovery.
Choice D rationale:
Multiple cleansing enemas are not routinely given to all surgical patients.
The decision to administer an enema is based on the specific type of surgery, the patient's condition, and other factors. In some cases, a single enema may be sufficient, while others may require more than one.
Correct Answer is A
Explanation
Choice A rationale:
Anticoagulant medications are the mainstay of treatment for thrombophlebitis. They work by preventing the formation of new blood clots and allowing the body's natural clot-dissolving mechanisms to break down existing clots. This helps to reduce the risk of the clot growing larger, breaking off, and traveling to the lungs (pulmonary embolism), which is a potentially life threatening complication.
Here is a detailed explanation of how anticoagulants work:
Blood clotting process: Blood clotting, also known as coagulation, is a complex process that involves multiple steps and factors. When a blood vessel is injured, a series of reactions occur to form a blood clot, which helps to stop bleeding.
Role of thrombin: Thrombin is a crucial enzyme in the clotting process. It converts fibrinogen, a soluble protein in the blood, into fibrin, which forms the mesh-like structure of blood clots.
Anticoagulants target thrombin: Anticoagulant medications work by inhibiting thrombin activity, thereby preventing the formation of fibrin and subsequent clot formation.
Different types of anticoagulants: There are several types of anticoagulant medications, each with different mechanisms of action. Some common types include:
Heparin: Heparin binds to antithrombin III, a natural anticoagulant in the body, and enhances its ability to inactivate thrombin and other clotting factors.
Warfarin: Warfarin blocks the production of vitamin K-dependent clotting factors in the liver.
Direct oral anticoagulants (DOACs): DOACs directly inhibit specific clotting factors, such as factor Xa or thrombin.
Choice B rationale:
Antibiotic medications are used to treat bacterial infections. Thrombophlebitis is not a bacterial infection, so antibiotics would not be effective in treating it.
Choice C rationale:
Antigen medications are not a category of medications. Antigens are substances that trigger an immune response in the body.
Choice D rationale:
Antihistamine medications are used to treat allergic reactions. They block the effects of histamine, a chemical released by the body during an allergic reaction. Antihistamines would not be effective in treating thrombophlebitis.
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