A nurse is assessing a patient with localized redness, warmth, and swelling in the lower limb. The patient reports pain and tenderness at the affected site.
Which nursing intervention is appropriate for this patient?
Administering anticoagulant medication.
Applying cold compresses to the affected area.
Encouraging the patient to ambulate frequently.
Administering acetaminophen for pain relief.
The Correct Answer is B
Choice A rationale:
Administering anticoagulant medication is not appropriate for a patient with localized redness, warmth, swelling, pain, and tenderness in the lower limb.
These symptoms suggest a potential inflammatory or infectious process, not a blood clot.
Anticoagulants are used to prevent or treat blood clots, and there is no indication for their use based on the presented symptoms.
Choice B rationale:
Applying cold compresses to the affected area is an appropriate nursing intervention for a patient with localized redness, warmth, swelling, pain, and tenderness.
These symptoms are indicative of inflammation or infection, and cold compresses can help reduce inflammation, relieve pain, and provide comfort to the patient.
Choice C rationale:
Encouraging the patient to ambulate frequently may not be appropriate at this stage.
Ambulation is generally encouraged to prevent complications such as deep vein thrombosis (DVT) in hospitalized patients.
However, in the presence of localized redness, warmth, swelling, pain, and tenderness, it is essential to identify the underlying cause and provide appropriate treatment and rest before promoting ambulation.
Choice D rationale:
Administering acetaminophen for pain relief is a reasonable option, but it addresses only the symptom (pain) and not the underlying cause of the patient's condition.
While pain management is important for patient comfort, it should be combined with interventions that directly address the inflammation or infection responsible for the symptoms.
Therefore, choice B (cold compresses) is a more appropriate initial intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The statement advises the patient to scrub the affected area vigorously with soap and water.
This is not appropriate for wound care in cellulitis.
Scrubbing the area vigorously can cause further damage to the skin, increase the risk of infection, and delay healing.
The use of harsh mechanical methods like scrubbing should be avoided in wound care.
Choice B rationale:
This statement correctly advises the patient to avoid cleaning the wound with hydrogen peroxide, as it may delay healing.
Hydrogen peroxide can be cytotoxic to healthy tissue and can slow down the healing process.
It's essential to use gentle, non-cytotoxic methods for wound cleaning.
Choice C rationale:
Keeping the wound uncovered is not recommended for proper wound care in cellulitis.
Open wounds are more susceptible to contamination, and covering the wound helps protect it from environmental contaminants and reduces the risk of infection.
Choice D rationale:
Applying antibiotic ointment multiple times a day may not be necessary and could potentially lead to antibiotic resistance.
It's essential to follow the healthcare provider's instructions regarding the frequency of antibiotic ointment application.
Overuse of antibiotics can have detrimental effects on both the individual and public health.
Correct Answer is A
Explanation
Choice A rationale:
Cellulitis occurs when the skin's protective barrier is compromised.
Cellulitis is a bacterial skin infection that occurs when bacteria enter the skin through a break or opening in the protective barrier, such as a cut, wound, or insect bite.
The bacteria then multiply in the underlying tissues, leading to inflammation, redness, warmth, swelling, and pain.
Choice A is correct because it accurately describes the pathophysiology of cellulitis, emphasizing the importance of a compromised skin barrier in its development.
Choice B rationale:
Cellulitis is primarily caused by a viral infection.
This statement is incorrect.
Cellulitis is primarily caused by bacterial infections, commonly by Streptococcus and Staphylococcus species.
Viruses do not typically cause cellulitis.
Choice C rationale:
Cellulitis leads to increased blood clot formation.
This statement is incorrect.
Cellulitis does not lead to increased blood clot formation.
Instead, it causes inflammation and infection in the skin and underlying tissues.
Choice D rationale:
Cellulitis results in excessive sweating in the affected area.
This statement is incorrect.
Cellulitis does not result in excessive sweating.
It causes localized symptoms such as redness, warmth, swelling, and pain, but sweating is not a characteristic feature of cellulitis.
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