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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Keeping legs abducted with a pillow between them prevents dislocation of the hip prosthesis after total hip replacement. This maintains joint stability by avoiding adduction and internal rotation, which can dislodge the implant, making it the correct intervention.
Choice B reason: Flexing the knee on the affected side risks hip dislocation, as excessive flexion (beyond 90°) strains the prosthesis. Abduction with a pillow is the standard to maintain alignment, making this an incorrect and unsafe action.
Choice C reason: Turning the patient to the affected side is not recommended, as it may cause the hip to adduct or rotate, risking dislocation. Abduction with a pillow ensures safe positioning, making this an incorrect intervention for hip replacement care.
Choice D reason: Changing the patient’s position is vague and does not specify safe technique. Specific positioning, like leg abduction with a pillow, is critical to prevent complications, making this choice too general and less appropriate than the targeted intervention.
Correct Answer is B
Explanation
Choice A reason: Potatoes do not contain substances that cause false-positive occult blood tests. They are low in heme and do not mimic blood in stool, making them safe to consume before testing.
Choice B reason: Red meat contains heme, which can cause false-positive results in occult blood tests by mimicking blood. Avoiding red meat for 48–72 hours ensures test accuracy, making this the correct choice.
Choice C reason: Yogurt lacks heme or oxidizing agents that interfere with occult blood tests. It is a safe food choice before testing, as it does not affect results, making this incorrect.
Choice D reason: Apples do not typically cause false positives, though some fruits with peroxidase (e.g., turnips) might. Apples are generally safe, making this less critical to avoid than red meat.
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