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.

Answer and Explanation

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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Correct Answer is C

Explanation

When contributing to the plan of care for a client who is postoperative following a total hip arthroplasty, the nurse should include information on preventing hip ﬂexion of the aﬀected extremity. This can help prevent dislocation of the new hip joint and promote healing.

Positioning the lower extremities so that they are touching is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the lower extremities should be determined by the surgeon's instructions and the client's comfort.

Ensuring that the client's heels are touching the bed is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the heels should be determined by the surgeon's instructions and the client's comfort.

Instructing the client to avoid movement of the aﬀected leg is not necessary for a client who is postoperative following a total hip arthroplasty. The client will need to begin moving and exercising the aﬀected leg as part of their rehabilitation and recovery.

A. Raise the head of the bed. B. Check the client for fecal impaction. C. Check the client's bladder for distention. D. Ensure the room temperature is warm.

Correct Answer is A

Explanation

If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreﬂexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.

Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreﬂexia, but it is not the first action the nurse should take.

Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreﬂexia, but it is not the first action the nurse should take.

Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreﬂexia.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

A nurse contributes to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?