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 ["B","C","E"]
Explanation
A. Pale, yellow urine: While pale yellow urine can be a symptom of a UTI, it is not specific enough and can be caused by other factors like dehydration or certain medications. Therefore, it is not a reliable indicator of a UTI in this case.
B. Cloudy urine: Cloudy urine is a more specific symptom of a UTI, as it can indicate the presence of white blood cells or bacteria in the urine. This finding, along with other symptoms, suggests a possible UTI.
C. Suprapubic pain: Suprapubic pain, which is pain felt above the pubic bone in the lower abdomen, is a common symptom of bladder infections, including UTIs. This finding is highly suggestive of a UTI in this client.
D. Temperature of 38.2 C (100.7 F): Although fever can be a symptom of a UTI, it is not always present and can be caused by other infections or conditions. Therefore, a single elevated temperature, without other supporting symptoms, is not conclusive for a UTI diagnosis.
E. Constant urge to urinate (dysuria): Dysuria, or a frequent and urgent need to urinate, is another common symptom of UTIs. This finding, along with cloudy urine and suprapubic pain, further strengthens the suspicion of a UTI in this client.
Correct Answer is D
Explanation
Choice A rationale:
Secondary prevention focuses on early detection and treatment of diseases or conditions to prevent complications or progression. It does not involve education about health promotion activities like exercise.
Examples of secondary prevention include:
Screening for cancer (e.g., mammograms, colonoscopies)
Regular blood pressure checks
Immunizations
Taking medications to manage chronic conditions (e.g., diabetes, hypertension)
Choice B rationale:
Restorative care aims to restore function and quality of life after an illness or injury. It does not encompass health education strategies like the nurse's action in this scenario.
Examples of restorative care include:
Physical therapy
Occupational therapy
Speech therapy
Rehabilitation programs
Choice C rationale:
Tertiary prevention focuses on managing existing diseases or conditions to prevent further complications and improve quality of life. It's not applicable to this scenario as no disease or condition is being managed.
Examples of tertiary prevention include:
Cardiac rehabilitation after a heart attack
Diabetes management education
Pulmonary rehabilitation for chronic lung disease
Choice D rationale:
Primary prevention targets preventing diseases or conditions from occurring in the first place. It often involves education and lifestyle changes to promote health and wellness.
The nurse's action of educating adolescents about physical exercise aligns with primary prevention. Exercise has proven benefits in:
Reducing the risk of chronic diseases like obesity, heart disease, stroke, type 2 diabetes, and some types of cancer Improving mental health and well-being
Promoting bone and muscle health
Enhancing sleep quality
Reducing stress levels
Therefore, the nurse's activity of educating adolescents about exercise represents primary prevention.
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