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A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.)

Place a compression bandage on the ankle.

Apply heat to the ankle.

Encourage rest.

Elevate the ankle.

Perform passive range-of-motion exercises to the ankle.

Answer and Explanation

Correct Answer : A,C,D,E

A. Place a compression bandage on the ankle.

- This helps reduce swelling and provides support to the injured area.

B. Apply heat to the ankle

- This action is not recommended for acute sprains as it can increase swelling. Cold packs or ice should be used initially to reduce inflammation.

C. Encourage rest.

- Rest is important to allow the ankle to heal properly and prevent further injury.

D. Elevate the ankle.

- Elevating the ankle helps reduce swelling by allowing fluid to drain away from the injured area.

E. Perform passive range-of-motion exercises to the ankle.

- Gentle range-of-motion exercises can help prevent stiffness in the ankle joint. However, it's important to perform these exercises within the limits of comfort and not force any movements.

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Correct Answer is C

Explanation

A. Mild erythema (redness) at the pin sites can be a normal finding due to the body's response to the presence of foreign objects. It may not necessarily indicate infection.

B. Serosanguineous drainage (a mixture of clear and bloody fluid) can also be a normal finding initially after the insertion of pins. It may not necessarily indicate infection.

C. Fever is a systemic response to infection. In a client with skeletal traction, fever can be an indication of an infection at the pin sites or a more systemic infection related to the traction device.

D. Warmth around the pin sites can be a normal finding due to the inflammatory response that occurs after pin insertion. It may not necessarily indicate infection.

A. Increase the client's protein intake. B. Administer antibiotics to the client. C. Provide the client with antipyretic therapy. D. Teach relaxation breathing to reduce the client's pain.

Correct Answer is B

Explanation

A. Increasing the client's protein intake is important for overall healing, but it is not the top priority in the acute phase of osteomyelitis. The immediate priority is to administer antibiotics to address the infection.

B. This is the correct answer. Administering antibiotics is the top priority in the treatment of acute osteomyelitis. Timely administration of appropriate antibiotics is crucial in eradicating the infection and preventing further complications.

C. Providing the client with antipyretic therapy (to reduce fever) is important, but it is secondary to administering antibiotics. The underlying infection must be addressed first and foremost.

D. Teaching relaxation breathing to reduce pain may be beneficial for the client's comfort, but it is not the priority intervention. Controlling the infection with antibiotics takes precedence.

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A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

Correct Answer is C

Explanation

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Correct Answer is B

Explanation

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