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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Poor hygiene.
Poor hygiene is a known risk factor for cellulitis.
Inadequate hygiene practices can lead to an increased risk of skin infections, including cellulitis.
Choice B rationale:
Diabetes.
Diabetes is a known risk factor for cellulitis.
People with diabetes are more susceptible to skin infections due to impaired immune function and poor circulation.
Choice C rationale:
Recent surgery or invasive procedures.
Recent surgery or invasive procedures are known risk factors for cellulitis.
These procedures can disrupt the skin's protective barrier, making it easier for bacteria to enter and cause infection.
Choice D rationale:
Allergic reaction to antibiotics.
This is not a known risk factor for cellulitis.
While allergies to antibiotics can cause various reactions, including skin rashes, they are not considered a direct risk factor for cellulitis.
Correct Answer is B
Explanation
Choice A rationale:
Reduced pain and swelling are not typically associated with abscess formation in cellulitis.
Abscesses are often characterized by localized pain, swelling, and the presence of pus.
The development of an abscess can indicate a more severe infection.
Choice B rationale:
Spreading of the infection to deeper tissues or the bloodstream (sepsis) is a potential complication associated with cellulitis when abscess formation occurs.
If an abscess forms, bacteria can enter the bloodstream, leading to sepsis, a life-threatening condition.
Early recognition and treatment are essential to prevent sepsis.
Choice C rationale:
Improved wound healing is not a typical outcome when cellulitis leads to abscess formation.
Abscesses can impede wound healing and may require drainage and antibiotic treatment to resolve.
Choice D rationale:
Decreased redness and warmth at the site are not expected outcomes when an abscess forms in cellulitis.
Abscesses are often associated with increased redness and warmth due to inflammation and infection.
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