A nurse is caring for a client who is receiving heat applications using a heating pad. Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the client's skin becomes red.

Leave the pad in place for at least 40 min.

Use safety pins to keep the pad in place.

Set the pad's temperature to 42.2° C (108° F).

Answer and Explanation

The Correct Answer is A

Choice A rationale: If the client's skin becomes red, the heat application should be stopped to prevent burns or skin damage.
Choice B rationale: Heat applications are generally recommended for 20-30 minutes, not at least 40 minutes, to avoid skin damage.
Choice C rationale: Safety pins should not be used to keep the heating pad in place, as they can damage the pad or cause injury to the client.
Choice D rationale: The temperature of the heating pad should be set to a comfortable and safe level, typically below 42.2° C (108° F).

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Correct Answer is C

Explanation

Choice A rationale: Using enemas should not be the first response to constipation. There are various types of laxatives with different mechanisms of action that can be tried before resorting to enemas.
Choice B rationale: Habitual laxative use can contribute to chronic constipation, but it is not the most common cause. It is essential to identify and address the underlying cause of constipation.
Choice C rationale: If laxatives are not effective, trying a laxative with a different mechanism of action may be more successful in relieving constipation.
Choice D rationale: Chronic constipation should be assessed and addressed, as it can lead to complications and should not be dismissed as insignificant.

A. Deep Tissue Injury B. Stage III Pressure Ulcer C. Unstageable Ulcer D. Stage IV Pressure Ulcer

Correct Answer is A

Explanation

Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.

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A nurse is caring for a client who is receiving heat applications using a heating pad. Which of the following actions should the nurse take when applying the pad?

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Naxlex Comprehensive Predictor Exams

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