The nurse is caring for a patient with swelling and redness following an ankle sprain. Which action by the nurse is most appropriate?

Apply a warm compress to the ankle

Elevate the ankle above heart level

Encourage weight-bearing exercises

Wrap the ankle tightly with a bandage

Answer and Explanation

The Correct Answer is B

Choice A reason: Applying a warm compress may increase swelling by promoting blood flow, which is contraindicated in acute sprains. Elevation reduces edema by gravity-assisted drainage, making warm compresses less appropriate for initial sprain management.

Choice B reason: Elevating the ankle above heart level is the most appropriate action, as it reduces swelling and redness by promoting venous and lymphatic drainage. This aligns with RICE (rest, ice, compression, elevation) protocol, making it the primary intervention for an acute sprain.

Choice C reason: Encouraging weight-bearing exercises is inappropriate for an acute sprain, as it may worsen injury and swelling. Rest and elevation are needed initially, with exercises introduced later in recovery, making this an incorrect action.

Choice D reason: Wrapping the ankle provides compression, which is helpful, but elevation more directly reduces swelling in the acute phase. Compression is a secondary RICE component, making elevation the priority for immediate swelling control in a sprain.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Tiny blood clots in the urine (hematuria) suggest urinary tract infection or trauma, not directly related to incontinence or mobility issues. Skin irritation from prolonged urine exposure is more expected, making this finding less likely in this patient patient.

Choice B reason: Skin irritation and redness in the perineal area are expected in urinary incontinence and impaired mobility, as prolonged moisture and pressure cause maceration and dermatitis. This is a common complication requiring skin protection, making it the correct finding finding.

Choice C reason: Increased urinary frequency may occur in incontinence but is not the primary concern compared to skin damage from constant moisture due to impaired mobility. Perineal irritation is a more direct consequence, making this less specific to the described scenario.

Choice D reason: Decreased urine specific gravity indicates dilute urine, unrelated to incontinence or mobility. It may occur in overhydration, but skin irritation from urine exposure is the most relevant finding in this patient context, making this incorrect incorrect.

A. Ask the client to state their name B. Check the client’s wristband C. Ask a family member to identify the client D. Compare the client’s face to the photo in the medical record

Correct Answer is B

Explanation

Choice A reason: Asking the client to state their name is useful but less reliable than a wristband, as confusion or language barriers may lead to errors. Wristbands provide objective identification, making this secondary.

Choice B reason: Checking the client’s wristband is the most reliable method, as it contains verified identifiers (name, medical record number). This ensures accurate identification, making it the correct action for verification.

Choice C reason: Asking a family member is unreliable, as they may be mistaken or absent. Wristbands provide standardized, objective identification, making family confirmation inappropriate and less accurate.

Choice D reason: Comparing the client’s face to a photo is useful but not always available or reliable, especially in emergencies. Wristband verification is standard and objective, making this a secondary method.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a patient with swelling and redness following an ankle sprain. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a newly admitted patient with urinary incontinence and impaired mobility. Which finding will the nurse expect?

Correct Answer is B

Explanation

A nurse is preparing to administer a medication to a client. Which of the following actions should the nurse take to verify the client’s identity?

Correct Answer is B

Explanation

Which of the following interventions should be included in the plan of care for a client who has a prescription for a clear liquid diet? (Select all that apply)

The nurse is caring for a diabetic patient in renal failure. Which laboratory findings are consistent with metabolic acidosis?

The nurse is educating the family of a patient with expressive aphasia from a cerebral vascular accident (CVA/stroke). Which statement by the family best indicates teaching was effective?

A nurse is caring for a client who has a prescription for NPH insulin 20 units subcutaneous daily. The nurse should plan to administer this medication at which of the following times?

The nurse is administering Ibuprofen (Advil) to an older patient. Which assessment data causes the nurse to hold the medication?

A nurse is preparing to suction a patient with thick oral secretions. Which finding will cause the nurse to stop suctioning?

The nurse is assessing a client who reports abdominal pain. Which of the following findings should the nurse identify as a possible indication of appendicitis?

A nurse is caring for a client who is receiving a blood transfusion. The client reports itching and hives. Which of the following actions should the nurse take first?