A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

Apply the elastic compression dressing tight enough so the toes and ankle become numb.

Place moderate weight on the aﬀected leg when walking.

Elevate the aﬀected ankle to the level of the heart.

Apply heat during the first 24 hr.

Answer and Explanation

The Correct Answer is C

The nurse should instruct the client to elevate the aﬀected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood ﬂow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.

a. The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
b. The client should avoid placing weight on the aﬀected leg when walking until advised by a healthcare provider.
d. Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inﬂammation.

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

Explanation

The nurse should identify absence of pulse, altered sensation of the toes, and cool skin as possible manifestations of compartment syndrome. Compartment syndrome is a serious condition that can occur following surgery or injury. It is characterized by increased pressure within a muscle compartment that can lead to decreased blood ﬂow and nerve damage.

Pain relieved by narcotics and capillary refill of 1 second are not manifestations of compartment syndrome. Pain relieved by narcotics is a normal response to pain medication. Capillary refill of 1 second is within the normal range and does not indicate compartment syndrome.

A. The weights rest against the foot of the bed. B. The ropes are in the center of the wheel grooves. C. The weights are equal on each side. D. The ropes atach securely to the pin

Correct Answer is A

Explanation

If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or ﬂoor. This ensures that the traction is providing the appropriate amount of force to the aﬀected limb.

The other options listed are not problems with the traction setup. The ropes should be in the center of the wheel grooves, the weights should be equal on each side, and the ropes should attach securely to the pin.

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A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

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A client returns to the surgical unit from the PACU in skeletal traction. The nurses should take action to correct. Which of the following problems with the traction setup?

Correct Answer is A

Explanation

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