A nurse caring for a patient who suffered a severe sprain and has an order for a cold pack application to the injured area would prevent patient injury by:.
using heavy pressure on the cold pack for greater effectiveness.
leaving the pack in place for over 30 minutes at a time.
preparing to apply heat instead if cold is not effective.
placing a towel between the pack and the skin.
The Correct Answer is D
Choice A rationale:
Using heavy pressure on the cold pack for greater effectiveness is not the correct approach when applying a cold pack to an injured area. Applying excessive pressure can lead to tissue damage, frostbite, and can be uncomfortable for the patient. Cold packs should be applied with gentle, even pressure to avoid complications.
Choice B rationale:
Leaving the cold pack in place for over 30 minutes at a time is not recommended. Prolonged exposure to cold can also cause tissue damage, including frostbite. It is generally advised to limit cold pack applications to 20-30 minutes at a time to prevent complications.
Choice C rationale:
Preparing to apply heat instead if cold is not effective is not the appropriate action in this scenario. When a healthcare provider orders a cold pack application, it is essential to follow the prescribed treatment plan. Heat should only be considered if it is specifically ordered as an alternative treatment.
Choice D rationale:
Placing a towel between the pack and the skin is the correct approach to prevent patient injury when applying a cold pack. This helps to protect the skin from direct contact with the cold pack, reducing the risk of frostbite or cold-related injuries. It ensures a barrier between the cold pack and the patient's skin, providing a safe and comfortable application.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
An elevated blood pressure is not a reliable indicator of a decrease in pain following the administration of an opioid narcotic. Blood pressure can be influenced by various factors, and it may not directly correlate with the relief of pain.
Choice B rationale:
The client being asleep is not a direct indicator of decreased pain following opioid administration. While opioids may cause drowsiness as a side effect, the absence of pain cannot be confirmed solely based on the patient's sleep state.
Choice C rationale:
An increased respiratory rate can be a reliable indicator of decreased pain following the administration of an opioid narcotic. Opioids often cause respiratory depression, so an increased respiratory rate may suggest that the patient's pain is adequately managed, as they are not experiencing excessive respiratory depression.
Choice D rationale:
Diaphoresis (excessive sweating) is not a direct indicator of decreased pain following opioid administration. Diaphoresis can be caused by various factors, including anxiety, and may not specifically reflect pain relief. .
Correct Answer is C
Explanation
Choice C rationale:
The most crucial instruction regarding the safety of fentanyl patches is to apply them as directed by the primary care provider. Fentanyl is a potent opioid medication, and its misuse or improper application can lead to serious health risks, including overdose. Therefore, following the prescriber's instructions is of utmost importance to ensure the patient's safety.
Choice A rationale:
Storing fentanyl patches in a locked cabinet is a good practice to prevent unauthorized access and to keep them out of reach of children or individuals who should not have access to the medication. However, it is not the most critical safety instruction. Proper application and usage are more important.
Choice B rationale:
While preparing the skin by cleaning with an antiseptic scrub solution is a necessary step when applying a transdermal medication like a fentanyl patch, it is not the most critical safety instruction. It is a standard part of the application process but does not address the overarching safety concerns related to fentanyl use.
Choice D rationale:
Using fentanyl patches as needed for breakthrough pain without clear guidance from a healthcare provider is not a safe practice. Fentanyl is a potent medication with a high risk of overdose, and its use should always be closely monitored and directed by a healthcare professional. Self-adjusting the dosage without medical supervision can lead to serious safety issues.
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