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. Lactated Ringer's is a balanced electrolyte solution, but it contains sodium in a similar concentration to normal serum levels. It is not appropriate for a client with hypernatremia, as it could further increase their sodium levels.
B. 0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
C. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
D. Dextrose 10% in water is a hypertonic solution with a high concentration of dextrose.
It does not contain sodium, but it is still a hypertonic solution and not appropriate for a client with hypernatremia.

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. When administering a cleansing enema, it is important to hold the container of solution about 30 cm (12 in) above the anus. This provides enough gravitational force for the solution to flow gently into the rectum.
B. This action involves unnecessary movement of the container and is not a standard technique for administering a cleansing enema.
C. Holding the container level with the client's upper hip does not provide sufficient height for the gravitational force needed to administer the enema effectively.
D. Keeping the container at a level to maintain client comfort is not specific guidance for administering a cleansing enema. The height of the container above the anus is a critical factor in ensuring the enema flows properly.

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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

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