A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?

Abdominal aortic aneurysm

Phlebitis

Osteoarthritis

Peripheral neuropathy

Answer and Explanation

The Correct Answer is D

A. Abdominal aortic aneurysm. While an abdominal aortic aneurysm is a serious vascular condition, it is not directly affected by localized heat therapy to an extremity such as the foot. However, heat should still be used cautiously near major vascular abnormalities.
B. Phlebitis. Heat therapy is often used to reduce inflammation and promote circulation in conditions like phlebitis. Although care must be taken, it is not an absolute contraindication and may actually be prescribed in some mild cases under supervision.
C. Osteoarthritis. Heat therapy is commonly used for osteoarthritis to relax muscles, improve joint mobility, and alleviate stiffness and discomfort. It is considered a beneficial and appropriate treatment modality for this condition.
D. Peripheral neuropathy. Clients with peripheral neuropathy may have impaired sensation, making them unable to detect excessive heat. This puts them at high risk for burns or thermal injury, making heat therapy a contraindication for safety reasons.

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Correct Answer is B

Explanation

A. Allow the second nurse to enter the data while observing them. Even if observed, allowing another person to use a computer while logged in under someone else’s credentials violates HIPAA and security policies.
B. Log off the computer and let the second nurse log on and enter the data. This is the correct and secure action. Each nurse must use their own login to ensure accountability and protect patient confidentiality, as required by HIPAA and institutional policies.
C. Ask the second nurse for the data and enter it for them. This may lead to documentation errors or confusion about who provided care. Each nurse should document their own assessments and interventions.
D. Tell the second nurse to enter the data when they return from their break. While delaying documentation is sometimes necessary, timely documentation is important for safe patient care. The second nurse should have the opportunity to chart promptly, but under their own credentials.

A. "I should visually monitor the client continuously when in mechanical restraints." B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." C. "I should expect the provider to evaluate the client within 4 hours of restraint application." D. "I should ask the provider to write a prescription for mechanical restraints as needed."

Correct Answer is A

Explanation

A. "I should visually monitor the client continuously when in mechanical restraints." Continuous visual monitoring is required to ensure the client’s safety, monitor for distress or injury, and assess the ongoing need for restraints. This is a key safety standard in the use of mechanical restraints.
B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." Skin integrity must be assessed much more frequently, typically every 15 to 30 minutes, to prevent injury or pressure-related complications while the client is restrained.
C. "I should expect the provider to evaluate the client within 4 hours of restraint application." For adults, a provider must evaluate the client within 1 hour of the initiation of mechanical restraints. A 4-hour delay does not meet safety or legal standards.
D. "I should ask the provider to write a prescription for mechanical restraints as needed." PRN (as-needed) prescriptions for restraints are not permitted. Each use must be justified, time-limited, and based on the client’s immediate behavior or condition.

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A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?

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Naxlex Comprehensive Predictor Exams

A nurse is documenting at a computer when a second nurse asks to use the computer to quickly document data before taking a break. Which of the following actions should the first nurse take?

Correct Answer is B

Explanation

A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

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