A nurse in an urgent care centre 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 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

An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure. The nurse can reduce stimuli by minimizing noise and light in the client's environment and limiting the number of visitors.

Administering opioids, applying restraints, and blackening the room are not appropriate nursing actions for this situation. Administering opioids can cause respiratory depression and is not recommended for clients with increased intracranial pressure. Applying restraints can increase agitation and is not recommended for clients who are restless. Blackening the room can disorient the client and is not recommended.

A. Reduction of the fracture B. Support for moving the extremity C. Alignment of the pins D. Relief from muscle spasms

Correct Answer is D

Explanation

The nurse should reinforce to the client that Buck's traction promotes relief from muscle spasms. Buck's traction is a type of skin traction that is widely used for fractures of the femur and hip². It uses splints, bandages, and adhesive tapes to position a limb near the fracture and then applies pressure using weights and pulleys. One of the goals of Buck's traction is to lessen or eliminate muscular spasms.

a. Reduction of the fracture is not the primary purpose of Buck's traction.
b. Support for moving the extremity is not a primary outcome of Buck's traction.
c. Alignment of the pins is not applicable to Buck's traction as it does not involve inserting pins into the
bone.

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A nurse in an urgent care centre 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 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?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

A nurse is assisting with 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. Which of the following interventions should the nurse include in the plan of care?

A nurse in an urgent care centre 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)

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

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 discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?