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 ["A","B","D","E"]

Explanation

A. More difficulty seeing due to a greater sensitivity to glare is a common age-related change in vision.

B. Dehydration of intervertebral discs can occur with aging, leading to decreased flexibility and potentially contributing to back pain.

C. While systolic blood pressure may increase with age, decreased systolic blood pressure is not a typical age-related change.

D. Decreased cough reflex is an expected change, which can lead to an increased risk of respiratory infections in older adults.

E. Decreased bladder capacity is an expected age-related change due to changes in the bladder muscles and elasticity of the tissues. This can contribute to increased frequency of urination in older adults.

A. Use a stiff toothbrush to clean the client's teeth. B. Turn the client on his side before starting oral care. C. Use the thumb and index finger to keep the client's mouth open. D. Apply petroleum jelly to the client's lips after oral care.

Correct Answer is B

Explanation

A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.

B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.

C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.

D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.

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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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