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. Independently disposing of the remaining medication may not be in compliance with facility policies and could potentially interfere with an investigation into how the medication was left unattended.

B. Returning the medication to the unit's stock for future use is not appropriate, as the vial is already open and its integrity may be compromised.

C. Administering the medication to other clients is absolutely not an option. This could lead to serious harm or even fatal consequences for the other clients involved.

D. When a nurse discovers an open vial of medication left unattended, it is a serious safety concern. The nurse should report the discrepancy immediately to the appropriate personnel or supervisor. This ensures that the situation is addressed promptly and that necessary actions are taken to prevent potential harm to clients.

A. Checking the pupillary response to light B. Eliciting the gag reflex C. Testing visual acuity D. Observing for facial symmetry

Correct Answer is A

Explanation

A. Cranial nerve III, also known as the oculomotor nerve, controls the muscles that move the eye and regulates the size of the pupil. Assessing the pupillary response to light helps evaluate the function of this nerve.
B. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
C. Testing visual acuity is primarily associated with cranial nerve II (optic nerve), not cranial nerve III.
D. Observing facial symmetry is important for assessing cranial nerve VII (facial nerve), not cranial nerve III.

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