A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30 min at a time.

Place the bag directly on the skin.

Allow room for some air inside the bag.

Reapply the bag 30 min after removing it.

Answer and Explanation

The Correct Answer is A

A.   Applying the ice bag for 30 minutes at a time is a recommended duration for cold therapy. This helps prevent potential tissue damage from prolonged exposure to cold temperatures.
B.   Placing the bag directly on the skin is not recommended, as it can cause frostbite or skin damage. A barrier, such as a thin towel or cloth, should be placed between the ice bag and the skin.
C.   Allowing room for some air inside the bag is important to allow the ice to conform to the shape of the injured area. However, the bag should not be overfilled with air.
D.   Reapplying the bag 30 minutes after removing it is a good practice, as it allows time for the tissues to warm up before reapplying the cold therapy.

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Correct Answer is B

Explanation

A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

A. Water heater temperature 54.4°C (130° F) B. Throw rugs C. Electric cords behind the furniture D. Raised toilet seats E. Bathtub with rails

Correct Answer is ["A","B"]

Explanation

A. A water heater temperature of 54.4°C (130°F) poses a burn risk, especially for older adults who may have decreased sensitivity to temperature changes. The recommended safe temperature for water heaters is usually around 49°C (120°F) to prevent scalding.

B. Throw rugs are a significant safety hazard as they can easily cause slips and falls, particularly for older adults who may have balance issues or mobility challenges.

C. Electric cords behind furniture do not pose an immediate tripping hazard, making this a lower safety risk compared to other options. However, cords should be checked for damage and overheating risks.
D. Raised toilet seats are typically considered a safety measure for older adults, as they can aid in sitting down and standing up, making it easier for individuals with mobility issues.

E. Bathtubs with rails are also a safety feature, providing support and stability for older adults when entering and exiting the tub, reducing the risk of falls.

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A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","B"]

Explanation

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