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 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.

A. Optimal nutrition and hydration B. Surgical debridement of necrotic tissue C. Antibiotic therapy D. Antipyretic therapy

Correct Answer is C

Explanation

The priority intervention for the nurse to implement for a newly admitted client who has acute osteomyelitis is antibiotic therapy. Osteomyelitis is an inﬂammatory condition of bone secondary to an infectious process. Antibiotics are the primary treatment option and should be tailored based on culture results and individual patient factors.

Optimal nutrition and hydration are important but not the priority intervention.

Surgical debridement of necrotic tissue may be necessary but is not the priority intervention.

Antipyretic therapy may be necessary but is not the priority intervention.

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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 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 is assisting with the care of a newly-admitted client who has acute osteomyelitis. Which of the following interventions is the priority for the nurse to implement?

Correct Answer is C

Explanation

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?

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

A nurse is collecting data from a client who has a short arm cast for a fractured wrist. Which of the following findings indicates impaired venous return in the aﬀected arm?

A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify which of the following factors can cause a myasthenic crisis.

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)