A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)
Apply a compression bandage to the client's ankle.
Apply heat to the client's ankle.
Encourage the range of motion of the client's foot.
Elevate the client's foot.
Check the client's toes for color, temperature, and sensation.
Correct Answer : A,D,E
These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.
Applying heat to the client's ankle is not recommended as it can increase swelling and inflammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the affected area.
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Related Questions
Correct Answer is B
Explanation
Boutonniere deformity is an expected finding for a client who has rheumatoid arthritis. It is a type of hand deformity that can occur in people with rheumatoid arthritis. It is characterized by a bent middle finger joint and a hyperextended fingertip.
Tophi, osteoma, and Heberden's nodules are not expected findings for a client who has rheumatoid arthritis. Tophi are deposits of uric acid crystals that can occur in people with gout. Osteoma is a benign bone tumor. Heberden's nodules are bony growths that can occur in people with osteoarthritis.
Correct Answer is B
Explanation
Checking capillary refill in the affected extremity every 4 hr is an important intervention for a nurse to include in the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. This helps to monitor the blood flow to the affected extremity and ensure that it is adequate.
a. Maintaining the client on bed rest for 72 hr after surgery is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's mobility should be determined by their individual needs and the surgeon's instructions.
c. Restricting oral fluid intake to 1,000 ml per day is not necessary for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's fluid intake should be determined by their individual needs and any medical conditions they may have.
d. Removing antiembolic stockings once each day to examine skin integrity is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The use of antiembolic stockings and their removal should be determined by the patient's individual needs and the surgeon's instructions.
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