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 A
Explanation
Choice A rationale:
If a patient with a Fentanyl patch is experiencing symptoms like abnormal sleepiness, slurred speech, and unsteadiness when ambulating, it could indicate an overdose or adverse reaction to the Fentanyl. In such cases, the patch should be removed immediately to stop the further absorption of the drug. Wiping off the skin can also help remove any residual medication. This is the correct choice as it addresses the issue at its source.
Choice B rationale:
Applying ice to the skin around the Fentanyl patch is not the appropriate action in this situation. Ice will not counteract the effects of a Fentanyl overdose or adverse reaction. The priority is to remove the patch and seek medical attention.
Choice C rationale:
Elevating the head of the bed and offering coffee or cola may be useful in combating some forms of sleepiness but would not be effective for someone experiencing an overdose or adverse reaction to Fentanyl. This choice does not address the problem's root cause and is not the appropriate action to take.
Choice D rationale:
Putting up the side rails on the bed does not address the issue of Fentanyl patch overdose or adverse reactions. This choice is not relevant to the situation and should not be chosen.
Correct Answer is A
Explanation
Choice A rationale:
Going to bed hungry or overly full can interfere with sleep. When you're too hungry, your body may be uncomfortable and unable to relax, making it difficult to fall asleep. Conversely, going to bed overly full can lead to discomfort, and indigestion, and may result in disrupted sleep. Therefore, it does not help the patient reach REM (Rapid Eye Movement) sleep faster.
Choice B rationale:
Overeating or going to bed hungry does not aid in reaching REM sleep faster. It is essential for individuals to have a balanced diet and avoid excessive hunger or fullness to promote a healthy sleep pattern. REM sleep is a stage of deep sleep that occurs cyclically throughout the night, and it is influenced by various factors, including individual sleep patterns and circadian rhythms.
Choice C rationale:
REM sleep, a stage of deep sleep, is not influenced by going to bed hungry or overly full. Instead, it is primarily regulated by the body's internal clock and sleep-wake cycles. Factors such as hunger or fullness may affect the quality of sleep but do not contribute to reaching REM sleep faster.
Choice D rationale:
False. Going to bed hungry or overly full does not have a direct impact on the patient's ability to reach REM sleep faster. REM sleep is a natural part of the sleep cycle and is influenced by various factors, such as circadian rhythms, sleep disorders, and medications, but not by the state of hunger or fullness.
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