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 A
Explanation
The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.
Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.
Correct Answer is B
Explanation
The statement that clients in skin traction have more mobility than those in skeletal traction indicates that the newly licensed nurse understands these therapies. Skin traction is applied directly to the skin using splints, bandages, or adhesive tapes and is less invasive than skeletal traction³. Skeletal traction involves placing a pin, wire, or screw in the fractured bone and ataching weights to it to pull the bone into the correct position¹. Because skin traction is less invasive and does not involve inserting a pin into the bone, clients in skin traction have more mobility than those in skeletal traction.
a. Skeletal traction being better than skin traction for reducing a fracture is not necessarily true.
c. Skeletal traction having less risk for infection than skin traction is not true.
d. Clients in skin traction having more discomfort than those in skeletal traction is not necessarily true.
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