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 D

Explanation

A. Initiative vs. guilt is the developmental stage for children aged 3 to 6 years, where they begin to assert control and power over their environment. This stage is not applicable for a 9-year-old child.

B. Autonomy vs. shame and doubt is relevant for children aged 1 to 3 years. This stage focuses on children developing a sense of personal control over physical skills and a sense of independence, which is not directly relevant to a 9-year-old.

C. Identity vs. role confusion typically applies to adolescents aged 12 to 18 years, where individuals explore their independence and develop a sense of self and personal identity, making it less relevant for a 9-year-old child.

D. Industry vs. inferiority is the stage for children aged 6 to 12 years, where they develop a sense of pride in their accomplishments and abilities. During this stage, children are learning to cope with new social and academic demands, making it essential for the nurse to consider the child's self-esteem and competence in managing their asthma and engaging in age-appropriate activities. This stage directly relates to the planning of home care for the 9-year-old child with asthma.

A. Hold the container of solution 30 cm (12 in) above the anus. B. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus. C. Hold the container of solution level with the client's upper hip. D. Keep the container of solution at a level to maintain client comfort.

Correct Answer is A

Explanation

A. This is the appropriate height to allow the fluid flow by gravity.
B. This is such a short distance and the fluid wouldn't flow as desired.
C. Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D. This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.

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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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