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.
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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Related Questions
Correct Answer is C
Explanation
An appropriate action to prevent hip dislocation in a client who is postoperative following a total hip arthroplasty is to place a wedge pillow between the legs. This helps to maintain proper alignment and prevent the legs from crossing or adducting, which can cause hip dislocation.
Placing a trochanter roll against the thigh, placing a sandbag on the lateral calf, and placing a footboard on the bed are not appropriate actions to prevent hip dislocation in this situation. A trochanter roll is used to prevent the external rotation of the hip. A sandbag to the lateral calf can help prevent foot drop. A footboard can help prevent plantar flexion contractures.
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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