A nurse is assisting with the care of a client who has frostbite on both legs after prolonged exposure to outdoor temperatures around 12.2° C (10" F). Which of the following actions should the nurse plan to take?
Warm the affected area in a water bath.
Administer the pneumococcal vaccine.
Massage the calf and thigh muscles.
Immerse the legs in cool water.
The Correct Answer is A
A. Warm the affected area in a water bath: The affected area should be rewarmed gradually using a water bath at 37° to 39°C (98.6° to 102.2°F) to minimize tissue damage.
B. Administer the pneumococcal vaccine: This is not related to the immediate treatment of frostbite.
C. Massage the calf and thigh muscles: Massaging frostbitten areas can cause further tissue injury and is contraindicated.
D. Immerse the legs in cool water: Cool water will not rewarm the tissue and could worsen vasoconstriction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lower the head of the bed: This facilitates a horizontal transfer by making the bed and stretcher levels even, reducing strain during the move.
B. Place the bed in its lowest position: The bed should be adjusted to the same height as the stretcher for a smoother transfer.
C. Unlock the wheels on the bed: The wheels must be locked to prevent movement and injury.
D. Have two caregivers at the side of the bed: While help is needed, one caregiver on each side and possibly one at the head or foot is preferred depending on the client’s condition.
Correct Answer is D
Explanation
A. Swing-to gait: This gait is used when both legs are non-weight bearing and the client swings both legs forward to the crutches.
B. Swing-through gait: Similar to swing-to, but the legs swing past the crutches-used for clients with paralysis or weakness in both legs.
C. Two-point gait: This is for clients who can bear partial weight on both legs, using the opposite leg and crutch together.
D. Three-point gait: Used when one leg is non-weight bearing. The client moves both crutches forward with the affected leg off the ground, then advances the unaffected leg.
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